Jame,
You are allowed to reject a provider's request for health benefit
information if you have restricted them from processing for reasons of
fraud or other legitimate reasons. You would use the AAA segment in the
2000A loop if the party sending identified in ISA08 or GS03 were restricted
from access, this may identify a provider, or a clearinghouse, or some
other submitter other than the actual provider. Or you can use the AAA
segment at the 2100B loop to indicate that the provider as the information
receiver is restricted from access.
Determination of restricted access is left to the health plan. It is
assumed that some sort of trading partner agreement exists between the
provider and payer to permit the exchange of EDI transactions. Therefore,
the provider should know they are being restricted, because you would
either discontinue your trading partner agreement or have advised them of
your terms.
The Eligibility Work Group at X12N did not feel we should provide
guidelines for legal or policy issues within the implementation guides, but
rather provide a means to report errors related to such issues.
Don Bechtel
Co-chair of X12N TG2 WG1 - Eligibility Work Group
"Jame" <[EMAIL PROTECTED]>@wedi.org on 08/28/2001 01:01:31 PM
Please respond to <[EMAIL PROTECTED]>
Sent by: [EMAIL PROTECTED]
To: <[EMAIL PROTECTED]>
cc:
Subject: Question: Rejecting a transaction.
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]
**********************************************************************
To be removed from this list, send a message to:
[EMAIL PROTECTED]
Please note that it may take up to 72 hours to process your request.
-------------------------------------------------------------------------------
This message and any included attachments are from Siemens Medical Solutions
Health Services Corporation and are intended only for the addressee(s).
The information contained herein may include trade secrets or privileged or
otherwise confidential information. Unauthorized review, forwarding, printing,
copying, distributing, or using such information is strictly prohibited and may
be unlawful. If you received this message in error, or have reason to believe
you are not authorized to receive it, please promptly delete this message and
notify the sender by e-mail with a copy to [EMAIL PROTECTED] Thank you
**********************************************************************
To be removed from this list, send a message to: [EMAIL PROTECTED]
Please note that it may take up to 72 hours to process your request.
