have been informed by a processor that when the subscriber (2000B) and patient (2000C) are the same that the 2010B N3, N4, and DMG records CANNOT be included; inclusion will cause a rejection error.
The following shows an example of a family seeing a provider. The subscriber has a 2000B loop which would contain the 2010BA N3, N4, and DMG segments and no 2000C loop. The dependents would then use the same 2000B loop followed with their 2000C and visit information loops. Under the interpretation that I am questioning above, the dependents of the subscriber would need to have a NEW 2000B loop without the N3, N4, and DMG segments before their 2000C and visit loops could be created. This results in an unnecessary 2000B loop.
I wish to know if the definition of “Situational” in this case of the 2010BA N3, N4, and DMG segments is the same as “Not Used” which results in a rejection error, or “Optional” which allows the continuation of processing with a possible informational warning.
The 2010BA N3, N4 and DMG segments are used only when the patient is the subscriber or considered to be the subscriber. The subscriber loop 2000B must be repeated in the subsequent claims as described in the 2000B HL04 element note #4. Refer to RFI 1512, which clarifies the ASC X12 position on rejecting or accepting transactions that do not comply with the governing TR3.
The response in RFI 1512 is as follows:
ASC X12 does not govern the receiver's actions when receiving a transaction that is not compliant with the specified implementation guide. Section 2.2.1.1 in TR3s published by the ASC X12 Insurance Subcommittee makes this clear with the statement "The receiver will handle non-compliant transactions based on its business process and any applicable regulations."