The TR3 clearly states that the subscriber address is required in the 271 response when the subscriber is the patient unless the response is a rejection and the address was not included in the 270 request. We have some subscribers who are covered but do not have an address loaded in our system. Usually this is a temporary situation; however, we do receive inquiries on these individuals while they do not have an address loaded. How should we respond to inquiries for these subscribers?
Should we build a 271 without the subscriber address? Note: On May 15 the Portal screener asked the submitter to clarify the last line of their RFI. They indicated the last line should have read:
Should we reject the request (when the address is required and cannot be returned)? If so, what reject reason code should be used in AAA03?
The Situational Rule of the 271 2100C loop, N3 – Subscriber Address Segment and N4 – Subscriber City, State, ZIP Code Segment reads; “Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7), but not required if a rejection response is generated and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender’s discretion but cannot be required by the receiver.”
Therefore, if either of the situations in the usage rule is met, the Subscriber address (at a minimum, data items N301 and N401) must be sent, and if not sent the 271 response would not be compliant with the TR3.
If the Address is not available in the Information Source's system at the time of the inquiry, to meet the requirement of sending at a minimum, the data items N301 and N401, a defined default value such as “ADDRESS UNKNOWN” could be returned.
If the Information Source decides to respond with a AAA – Request Validation rejection if a compliant 271 cannot be created at the time of the inquiry due a temporary system limitation, it should be at the 2000A Loop with the AAA03 equal to 42 – Unable to Respond at Current Time.