Is it acceptable for a payer to suppress eligibility data for a health plan member experiencing identity theft? Occurring when a member shares the same demographic information with an entirely different member with another health plan.
An eligibility inquiry comes in with name and date of birth. If there is a match, then the 271 response returns a member ID. That member ID is then used to submit claims. However, the submitted claim is for a different person with the same name and same DOB, but who is not a member of our health plan. They belong to another health plan. We are receiving claims for the wrong member, paying, and then needing to retract payment. This often occurs in ambulance transactions and is passed on to the hospital. Our fraud department is trying to minimize erroneous member exposure and billing. What we would like to do is flag the member in our system and when an eligibility inquiry is received, respond with “member cannot be found.” Is this approach appropriate under guidelines? Any advice on other ways this can be handled?
The 270/271 TR3 outlines requirements that if all 4 pieces of the primary search option are sent in a 270, the information source must return, if a match is made, that the member has active or inactive coverage. The information source may return “member not found” when the information used from the 270 does not match a member in their system. If the member has been given a replacement identification number as a result of possible identity theft, the “member not found’ error is valid and accurate as that original ID is no longer valid. If no replacement identification has been assigned, or if it is preferred by the information source, an EB01 = 8 (Inactive – Pending Investigation) may be an advantageous solution as it could be used in a subset of situations for more focused purposes, such as identity theft cases.
The information source is recommended to use the member ID on the 270 inquiry as one of the primary components of a search and not use only the name and date of birth.
The expectation is that demographic information required on a subsequent EDI transaction, such as the 837 claim encounter, must be returned on the 271 (See Section 1.4.7.1 Items 3 and 4). With that, the information source to which the 270 was sent and the 271 returned from should be the information source that the claim would be sent to with the identifying information returned on the 271 after a positive member match was made and an active policy found for the dates of service in question.
It is unlikely that, at the point of the 270/271, the information source would be able to recognize the member submitted on the 270 was actually an unrelated member that belonged to another payer to know to flag that the member as victim to identity theft. It would make more sense to use information on the claim to cross-verify the member on the claim with the membership in the system (using the same information returned on the 271 to validate against the data required on the claim, such as street address, city, state, and ZIP).
It is important for the provider who will subsequently be sending the claim to the information source to verify that the information source the eligibility and benefit inquiry was sent to is the same information source the claim should be sent to.
While outside of the purview of X12, one suggestion is to provide the member with a newly assigned member identifier and prohibit the use of the original ID in the information source’s eligibility/benefits and claims adjudication systems.