Section title: Requests for Interpretation
RFI #
2330
Billing Provider contracted
Description

Our vendor for Senior Health Plan and Advantage Medicare Plan preventive dental service benefits sends us 837D transactions of dental claims. We require an indication on the transaction if the billing provider is contracted or non-contracted. The vendor suggested providing that indicator on a K3 segment, but I discouraged it because there is no regulatory body involved in this requirement. I don't see anywhere in Loop 2000A or 2010AA where such an indicator could be reported. Would the Loop 2300 NTE segment be appropriate for this purpose? Also, I reviewed RFI 1030, but it's not clear to me if the issue is the same.

Response

The 005010X224A2 Health Care Claim: Dental (837) updated the CLM07 to indicate the plan participation.
CLM07 element note:
Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.

RFI Recommendation

In this case, the CLM07 value would be C - Not Assigned to indicate that the provider is not participating with the plan.

DOCUMENT ID
005010X224A3