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Back  RFI # 970: 5010 271 PCP

Formal vs. Informal Help Informal Formal

Submitter

Boyle-Campbell Donna

Description

5010 271 requires Primary Care Provider be returned in 2120C/D, if known. Please clarify if PCP is being used in the general sense, but applies when there's either a PCP or HMO provider acting as PCP? Also, when requiring PCP be returned, what "type" of information is expected to be returned? Just the provider itself? Or is the PCP contact information required to be returned as well by the Info Source? and finally, if "dental care" is returned because it's now required if it's a covered benefit, does the PCP information return requirement also apply when there's a dental HMO/PCP provider?

Submitter Assigned Keywords

PCP

Response

This issue is explicitly addressed in guide 005010X279. The 2120C/D situational rule states "Required when needed to identify an entity associated with the eligibility or benefits being identified in the 2110C loop such as a provider". Therefore, PCP information is required whenever a PCP is associated with the eligibility or benefit information. This includes dental coverage situations as well. The situational rule is not restricted to any specific service types, and applies to all service types.

As to the specific information that must be conveyed, the specific situational rules determine those requirements on a segment and element level. For instance, the situational rule for the contact information (PER segment) states "Required when Contact Information exists and is available." Therefore, the contact information is required when it exists and is available, which is likely to be all of the time for a PCP situation.
Submission 2/22/2010
Status Date 6/15/2010
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page20
Set ID271