Under what circumstances is it allowable to reject a provider's request?
For example, if a provider submits a 270 request for eligibility
verification, but we have the provider on an ROP (Restriction of processing,
for suspected fraud or some other reason.) Can we use the AAA segment to
reject the request and indicate that the provider is not eligible or has
access/authorization restrictions?
Are there any guidelines for this? The implementation guide doesn't give
any guidance as to when refusing a request is allowable and when refusing a
request could be considered a compliance violation. How much discretion
does the payer have? It seems that if a provider's license is revoked,
there is probably no issue with this type of response, but what about other
situations like ROP?
We are a national payer with contracted providers in every state, but only
50% or 60%/40% of our claims volume is with PPO providers, the rest is with
providers where we have no agreements. Therefore the ability to perform a
270/271 is a great benefit for us, however the ability to reject such
requests is also a business need. Similar situations could also exist with
a claims status transaction.
Thanks for any input!
Jim Griffin
Business Systems Analyst
CNA Federal Markets
[EMAIL PROTECTED]
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