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Mary,
The
bottom line in this discussion is SBR02.
Either
it has a value of 18 (Self) or it must not be used.
The
actual note in the Professional Claim guide says:
"Required when the subscriber is the same person as the patient. If
the subscriber is not the same
person as the patient, do not use this element."
You
can't have it both ways. Therefore, you must repeat the 2000B loop in
order to have claims for the subscriber and one or more
patients.
This
topic has been discussed at length in the Health Care Claims workgroup at
X12N. Please see the draft copies of the 4050 guides for a clearer
presentation of the intent of the workgroup.
Tom Drinkard
EDIT, Inc.
Co-Chair X12N/TG2/WG2 (Health Care
Claims)
(678) 795-1251 (voice)
(775) 458-6117 (fax)
Tom,
My
take on it is different, and I may be wrong, but it would seem that the HL04
would indicate whether or not this Subscriber has Dependents, but the
Subscriber him/her self "could" be a Patient within the same
grouping.
I do
not see anywhere in the guide that says the Subscriber needs to be repeated in
the case where there are also Dependents.
Subcriber1(2000B,2010BA,2010BB)
HL*3*2*22*1 <
this "1" says this hierarchical level has a Dep.
SBR*P*18*....
< the "18" is required because this Subscriber is the
Patient.
CLM
(2300)
for this Claim.
Services (2400)
......
Patient 1(2000C,2010CA) ..
Subscriber1 Dependent
HL*4*3*23*0 < this Hierarchy points to the
Subscriber1 as its parent.
PAT*01*... < Spouse of
Subscriber1
CLM
Services
Patient 2 (2000C,2010CA) .. Subscriber1
Dependent
HL*5*3*23*0 < again, points to
Subscriber1
PAT*19*... < Child of
Subscriber1
CLM
.Subscriber2.......
The example on the bottom of page 38 - 40 of the 837 X098
(Professional) does show the above construct gave me that impression as
it depicts Subscriber #4 with both a Claim AND a Dependent with a Claim.
Please let me know if I am reading that wrong.
I
thought I was pretty comfortable with HL Parent/Child constructs in having
done a number of 856s in Retail EDI.
Respectfully,
Mary
Burkinshaw
Axiom Systems, Inc.
Actually neither option is correct. You cannot mix a
subscriber's with a patient's claims, unless you repeat the subscriber
loop.
Given this premise, then if you modify option one by copying line one
between lines three and four you would have a valid transaction set.
The end result would be as follows:
OPTION1
1.
Subcriber1(2000B,2010BA,2010BB)
2.
Clm(2300)
3.
Service(2400)
3.5.Subcriber1(2000B,2010BA,2010BB)
4. Patient 1(2000C,2010CA)
5.
Claim
6. Service
7. Service
8. Patient
2
9.
Claim
10. Service
11. Claim
12. Service
13. Service
14.Subscriber2.......
Tom Drinkard
EDIT,
Inc.
(678) 795-1251 (voice)
(775) 458-6117 (fax)
For 837P, I have a question regarding mutiple
claims for one patient. For example in a transaction, Subscriber1 has two
dependents. Subscriber1 has one claim, one claim for dependent
Patient1, two claims for dependent Patient2.
Which is a right approach - option1 or
option2(Notice the difference at line 11). Or, am I thinking in a
wrong track, as mutiple claim lines for one patient under same Provider in
same transaction set will not occur(only mutiple service lines).
Thanks in advance.
OPTION1
1. Subcriber1(2000B,2010BA,2010BB)
2.
Clm(2300)
3.
Service(2400)
4. Patient
1(2000C,2010CA)
5.
Claim
6.
Service
7.
Service
8. Patient 2
9.
Claim
10.
Service
11. Claim
12.
Service
13.
Service
14.Subscriber2.......
OPTION2
1. Subcriber1
2.
Clm
3.
Service
4. Patient 1
5.
Claim
6.
Service
7.
Service
8. Patient 2
9.
Claim
10.
Service
11. Patient 2
12. Claim
13.
Service
14.
Service
15.Subscriber2.......
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