Section title: Requests for Interpretation
RFI #
2430
Payer Requirements and Provider Lab Unique Test Codes
Description

Payer requirement states in-network, freestanding, outpatient hospital lab claims for most lab testing services (there are some outlined exceptions) must contain the provider laboratory's unique test code. The payer is looking for the unique test code, which providers must register with the payer up front, to be reported in Loop 2400 Service Line Number in the NTE - Notes section with a TPO qualifier in either the appropriate 837P or 837I claim.

The requirement applies to most of the payer's Commercial, Medicare Advantage and Community Plan networks. We believe the requirement to use the 837I and 837P 2400 NTE segment with the TPO qualifier is not allowed by X12 Standards. This segment is not for Provider use per the 5010 837I nor the 5010 837P IG. We do not want to spend resources to support a requirement that is not compliant per the 837I and 837P IGs.

Response

The 2400 NTE segment situational rule is clear that it cannot be used by Providers. It is only used when a Third Party Organization (TPO) or repricer needs to send additional information to the payer that is not supported elsewhere within the transaction.

Situational Rule: Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send.

A payer cannot require data in any NTE segment in the 837 transactions

RFI Recommendation

You may submit an ASC X12 change request it if there is a business need not supported in a published TR3  for consideration in a future version of the TR3.

DOCUMENT ID
005010X222 005010X223