Jan,
In the institutional guide, Loop 2010AA
NM108 only has 24 (Employer Identification Number), 34 (Social Security Number)
and XX National Provider ID. There really is no qualifer in the NM1
segment for submitting current provider numbers. So you are really forced
to use the REF segment until the national provider id is
implemented. Applies to both guides if your number for the provider
is not thier social security or employer ID.
joanne
----- Original Message -----
Sent: Friday, September 07, 2001 10:52
AM
Subject: Re: Situational Data
Elements
Candice
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
[EMAIL PROTECTED]
This message has been prepared on resources owned by Kent County, MI. It
is
subject to the Acceptable Use Policy of Kent County. Candice
Craig, CMH,
616-336-8930.
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