I would echo what Rachel said and add that mis-identification of subscriber and dependent happens all the time, today. Patients are often unaware of whether they are a 'dependent' or a 'subscriber' on a plan. The provider submitting the eligibility inquiry or claim takes their best shot at guessing. Payers are free to be strict and reject/deny transactions where the individual is mis-identified, or to be more lenient and, if they can match the individual somewhere in the member files, go ahead and process the transaction. The 'price' of rejecting a transaction for misidentification will probably be a phone call so it may be to the payers' economic advantage to persue a more lenient policy, at least part of the time.
Jan Root Rachel Foerster wrote: > Alex, > > For something misidentified in this manner, you would have to make your own > determination as to what response you would give back...but, again, I would > think that if given the information provided on the inbound 270 you can be > certain you've identified the correct individual in your system, why not > return a meaningful answer. After all, the intent here is to avoid requiring > the provider to make a phone call. > > In any case, it's still a business decision as to what you want to do in the > scenario you describe. > > Rachel > > -----Original Message----- > From: Alex Chernyak [mailto:[EMAIL PROTECTED]] > Sent: Monday, April 29, 2002 10:30 AM > To: [EMAIL PROTECTED] > Subject: RE: Subscriber vs. Dependent > > And how about when the provider marks the subscriber as a patient (2100D) > but submits the details for a dependent (2200E) or vice versa? > > >>> "Rachel Foerster" <[EMAIL PROTECTED]> 04/25/02 09:15PM >>> > Jonathan, > > I'm sure/hope others here will also respond, but here's my take on your > questions: > > 1. If the patient is NOT the subscriber, the patient HL should be created, > even in the absence of knowing the member id for the patient. If the patient > is the subscriber, then ONLY the subscriber HL should be created with as > much identifying information as can be obtained, keeping in mind the minimum > data required for subscriber/patient identification. > > 2. If the information source can accurately and unequivocally ascertain that > the individual being queried about is the same individual in their system, I > would recommend responding even if the individual is not the subscriber, but > putting the individual's information in the appropriate HL structure. > > Of course, in both cases, you'd have to determine your own business rules > for these responses, since the implications could be different if the query > was for eligibility versus authorization/referral. > > Rachel > Rachel Foerster > Principal > Rachel Foerster & Associates, Ltd. > Professionals in EDI & Electronic Commerce > 39432 North Avenue > Beach Park, IL 60099 > Phone: 847-872-8070 > Fax: 847-872-6860 > http://www.rfa-edi.com > > -----Original Message----- > From: Jonathan Fox [mailto:[EMAIL PROTECTED]] > Sent: Thursday, April 25, 2002 5:13 PM > To: [EMAIL PROTECTED] > Subject: Subscriber vs. Dependent > > I have a question regarding the X12 transaction sets named under HIPAA that > use the subscriber and dependent HL structure. More specifically the > inquiry/response transactions. > > If the information receiver (provider) does not know the patient's member > id, how should they build the transaction set? Should they put the patient > information at the subscriber or the dependent level? > Likewise, if the inquiry comes in at the subscriber level, and the member is > NOT the subscriber, should we respond? > > Any guidance would be greatly appreciated!!! > > Jonathan Fox > eCommerce Analyst > Independent Health > > CONFIDENTIALITY NOTICE. This e-mail and attachments, if any, may contain > confidential information which is privileged and protected from disclosure > by Federal and State confidentiality laws, rules or regulations. This > e-mail and attachments, if any, are intended for the designated addressee > only . If you are not the designated addressee, you are hereby notified > that any disclosure, copying, or distribution of this e-mail and its > attachments, if any, may be unlawful and may subject you to legal > consequences. If you have received this e-mail and attachments in error, > please contact Independent Health immediately at (716) 631-3001 and delete > the e-mail and its attachments from your computer. Thank you for your > attention. > > ---------------------------------------------------------------------------- > -- > CONFIDENTIALITY NOTICE: This message is intended only for the > use of the individual or entity to which it is addressed and may contain > information that is privileged, confidential or exempt from disclosure > under applicable law. If the reader of this message is not the intended > recipient or the employee or agent responsible for delivering the message > to the intended recipient, you are hereby notified that you are strictly > prohibited from printing, storing, disseminating, distributing or copying > this communication. If you have received this communication in error, > please notify us immediately by replying to the message and deleting it > from your computer. Thank You, Antares Management Solutions. > > ============================================================================ > ==
