For things like secondary patient identification numbers (actually any secondary/additional identification numbers), yes, payers may require that the provider submit that information (hopefully you've got some easy way for the provider to get that information in the first place!). The requirement here is not a syntax requirement (these secondary ID REFs are situational as you point out). The requirement here is a business requirement. Secondary ID REFs are situational in the imp guide because not all payers use more than one ID. Payers may require this information as a business decision if they need it to find the patient in their adjudication/eligibility/whatever files. This is one of the key pieces of information that payers should be telling providers: "Put this number in the NM109 and this other number in the REF using (you pick) qualifier." The guide is meant to encompass many different situations. In many ways it is a floor upon which you build your business decisions.
[Also, remember, the primary patient identification number goes in NM108/09. The REF is only used if you require more than one number to identify the patient (recalling that Plan/Group Name/Number are carried in SBR03 & 04).]
I always like to think of implementation has having three levels of
control
1: Imp guide syntax: this varies from guide to guide, but generally
speaking, if an element is required, then it must be sent. If there
is a syntax problem with a transaction, then it can be rejected on those
grounds. Basically, this means that if something is required then
it is sent (realizing that it's not always easy to figure out when an element
is required).
2. Business decisions: If you need 2 numbers to identify a patient
or a provider, then you can make a business decision to require two numbers
in your adjudication process. There is usually room in the 837 (and
other transactions) for more than one identifier for many entities.
Here, if a transaction comes in with only one number and you need two,
then it can be rejected as not meeting your business needs (you can't locate
the patient). Just make sure your provider base knows which two numbers
you need and where to put them in the imp guide (and which qualifier(s)
you prefer)
The guide does limit the scope of certain
business decisions. For example your system might be able to handle
100 lines on a professional claim. The 837P is limited to 50 lines.
Hence, all your 100 line claims will now come in on two claims. You
are not allowed to make a business decision to accept 100 line claims.
However, you can still make the business decision that "these services
must be split out this way and these other services must be split out another
way, and these must be lumped, etc., etc.".
3. Customary practices. These are of necessity vague and
vary from region to region, but they still exist and most contracts have
something in them about following customary billing practices.
Hope this helps.
j
Candice Craig wrote:
The 837 Professional IG states (page 49) if no rule appears in the notes for
a situational element, the item should be sent if available to the sender.
As a payer (receiver) can we require the provider (sender) to collect and
therefore transmit the information? For example, using Loop 2010CA -
Patient Secondary Identification (page 166). This loop is situational if
additional information is required to adjudicate the claim/encounter. If we
require social security numbers for reporting to the state, can we require
that this loop be always used to collect social security numbers? It is not
necessary to process the claim, but we must use it when reporting encounters
to the state.Thanks for any input!
Candice Craig
GUI Designer/HIPAA Implementation Team
Kent County Community Mental Health
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