Both forms of Situational Rule state, “Required when <explicit condition statement>". Who is the authority for determining whether or not <explicit condition statement> is true or false:
¤ ONLY the transaction sender?
¤ ONLY the transaction receiver?
¤ EITHER the transaction sender or transaction receiver?
¤ BOTH the transaction sender AND transaction receiver; via a mutual Trading Partner Agreement or similar document?
In all instances, the transaction sender determines whether or not the Situational Rule's explicit condition statement is true or false. In some cases, the transaction receiver may have enough information to validate the sender’s determination. As explained in RFI 1512, if the transaction receiver believes the transaction is non-compliant, the receiver will determine its course of action based on its business practices and applicable regulations.
Here are examples:
ONLY the transaction sender has enough information to make the determination.
Health Care Claim: Professional (837), QTY – Ambulance Patient Count
Situational Rule: Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
In this case, the transaction sender provided the service and knows the number of patients transported, while the transaction receiver does not have prior knowledge of the transportation circumstances.
BOTH the transaction sender and transaction receiver have enough information to make the determination.
(1) Health Care Claim Payment/Advice (835), loop 2100, CLP05 – Patient Responsibility Amount
Situational Rule: Required when the patient’s responsibility is greater than zero. If not required by this implementation guide, do not send.
In this case, either the transaction sender or receiver can sum the CAS*PR amounts to determine if the Patient Responsibility Amount is greater than zero and therefore whether the CLP05 data element must be present.
(2) Health Care Claim: Professional (837), loop 2400, CN1 – Contract Information
Situational Rule: Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
In this case, both transaction sender and receiver have access to their contractual agreement.
ONLY the transaction receiver has enough information to make the determination.
We cannot find an example of this case. If only the receiver could evaluate the situational rule, the sender would not know how to create a compliant transaction.