Section title: Requests for Interpretation
Service Authorization EDI Request Being Redirected

Is the Health Plan HIPAA 5010 compliant if they accept a 278 service authorization request but then redirect the submitter to then call to request the authorization?  Below is the direction from their companion guide:

“Authorizations that contain radiology, oncology, radiation therapy and cardiology codes need to be submitted to “Payer A” XXXXXXXX.  For “Payer B” XXXXXXXX, please contact “Payer A” XXXXXXXX at XXX-XXX-XXXX.  For “Payer C” XXXXXXXX, contact “Payer A” XXXXXXXX at XXX-XXX-XXXX.


We submit a valid, compliant request for authorization for a radiology service. The plan responds with a AAA response and directs the Provider to call to request the authorization. If this is a valid response, this would enable the plan to blanketly ignore the request and redirect, for every service they require to be authorized, to force the Provider to call.

Comment from “Payer B” XXXXXXX. “We do accept 278A’s for Radiology services, if submitted directly from a provider we respond with a redirect message to “Payer A” XXXXXXXX, (2013). Within the “Payer A” XXXXXXXX process they have automated the questionnaire(s) that enable auto decisioning, request for additional information, P2P, and all other downstream processes."

RFI Response

It is acceptable for the payer to respond to a submitted 278 with either an AAA or HCR segment to indicate why a transaction cannot be processed.