Section title: Requests for Interpretation
RFI #
2373
Network Leasing Segment 835
Description

Virginia House Bill – Network Leasing. Part of the VA House Bill askes the insurer to identify the contract source relied upon to discount a payment or reimbursement to the provider. More specifically, the remittance advice shall include the name of the third-party administrator or leasing agent. The 2100 loop, REF02 could handle the name of the leasing entity, but a qualifier for REF01 isn’t available for such information. Does the 835 hold another freeform segment for usage to accommodate the need of the house bill requirement?

Response

No, the 835 transaction does not include a free-form text segment. Section 1.10.2.15 PPOs, Networks and Contract Types does include the following information:  ”Many payers may encounter a situation where a particular provider has contracted with several different Preferred Provider Organizations, contract types or networks (PPOs) offered by that payer.”  And  "The specific need for identification is determined by the business alignment of the health plan and how that determines payment to providers rather than any objective concept of network or product line."

Although the CE qualifier (Class of Contract Code) in the 2100 REF Other Claim Related Information segment does not exactly match the business situation described, using this qualifier would allow reporting of the information in REF02. The REF02 element supports 50 characters, allowing the payer to identify their contract source / leasing agent. As long as that doesn't exceed the 50 character maximum size, there should be no problem. Of course, the format and usage should be conveyed to providers via any trading partner agreement or companion guide.

RFI Recommendation

The submitter should submit a maintenance request at www.x12.org for a new qualifier to meet the exact need for this business scenario.

DOCUMENT ID
005010X221