We are consolidating two health plans. Consolidation of payer brands, payer trading partner ID, EDI intake applications and sources of claims status response will take many years. In the interim, we know we will have members that will have claims processed in both plans and source systems. We are able to direct an inbound 276 request received by either payer/EDI intake application to both back-end source systems; we are working to determine best way in which to communicate multiple source system claim statuses in a 277 response to a 276 real-time request when multiple responses are present.
1. Submitter sends 276 real-time request to one payer (source system)
2. Plan receives 276 request and sends requests to two internal source systems
3. Claim statuses are found in both source systems and 277 response is generated from both source systems
4. Both source system responses to be sent to requester
Option 1:
Respond with two Information Source loops (2000A), each Information Source Loop containing response from one of the source systems. 271 response structure would be:
Information Source (2000A) – plan to which submitted
Information Receiver (2000B) – plan to which submitted
Service Provider (2000C) – plan to which submitted
Subscriber (2000D) - A – plan to which submitted
Claim Status Response (2200D) – plan to which submitted
Claim Status Response (2200D) – plan to which submitted (when multiple present)
Information Source (2000A) – second source plan
Information Receiver (2000B) – second source plan
Service Provider (2000C) – second source plan
Subscriber (2000D) - A – second source plan
Claim Status Response (2200D) – second source plan
Claim Status Response (2200D) – second source plan (when multiple present)
Option 2:
Respond with one Information Source loop (2000A) and multiple subscriber loops. There would be no identification that claim status response was from different source systems. 277 response structure would be:
Information Source (2000A) – plan to which submitted
Information Receiver (2000B) – plan to which submitted
Service Provider (2000C) – plan to which submitted
Subscriber (2000D) – plan to which submitted
Claim Status Response (2200D) – plan to which submitted
Claim Status Response (2200D) – plan to which submitted (when multiple present)
Subscriber (2000D) – second source plan
Claim Status Response (2200D) – second source plan
Claim Status Response (2200D) – second source plan (when multiple present)
The Healthcare Claim Status Request and Response (276/277) (005010X212) does not prohibit the use of either option. We do note that use of option 1 (returning both information sources) may be dependent upon the Payer Identifier (Loop 2100A NM109) established for use through trading partner agreement if each information source has a different Payer Identifier. Additionally, in either option the 277 response must reassociate with the submitted 276 request. This is accomplished by the value reported in Loop 2200D or 2200E TRN02 of the 277 response containing the same TRN02 value submitted in the 276 request.