What is the correct way for a payer to respond to a syntactically valid version 005010 270 request that has Loop ID-2000D (Dependent Level) populated if the health plan does not support dependents at all? Should they return a 999 or a 271, or are both allowed? If a 271 is allowed, then which AAA03 code should they use? Assume that the 270 Loop ID-2100C (Subscriber Name) NM1 segment was populated with the correct name and member ID for an active subscriber.
There are health plans (information sources), particularly state Medicaid agencies, that do not support dependents at all. Every plan member must enroll as an individual subscriber. Providers (information receivers) sometimes incorrectly populate a 270 request Loop ID-2000D (Dependent Level) anyway, even though they are not supposed to. In that case, we have seen payers return a 271 with Loop ID-2110D (Dependent Eligibility or Benefit Information) AAA03 = "33" (Input Errors), which seems inappropriate and leaves the provider confused about what they did wrong in the request. We understand that providers should not include a dependent in requests to health plans that do not have dependents, but sometimes providers make mistakes.
- It is more appropriate to use the AAA03 value indicating what was missing that was expected to successfully process a 270. The AAA can advise the business issue encountered; using the AAA03 value of 58 (Invalid/Missing Date-of-Birth) and AAA03 value of 73 (Invalid/Missing Subscriber/Insured Name) will explicitly indicate what was expected in the 2100C loop that was not sent and can be used in combination with AAA04 to advise the information receiver what to send on their subsequent 270 inquiry.
- AAA03 = 33 is not compliant with the TR3 if it is not being used to indicate an issue with what came in on the 270 in the corresponding 2110 loop as the situational rule on the 2110D AAA segment states, “Required when the request could not be processed at a system or application level when specifically related to specific eligibility/benefit inquiry data contained in the original 270 transaction’s dependent eligibility/benefit inquiry information loop (Loop 2110D) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.”
- If it is unknown if patient is a subscriber or dependent in the information source’s system, the following recommendation in 1.4.8 Search Options states, “If there is confusion as to whether the patient is a subscriber or a dependent, the transaction should be submitted with the patient as the subscriber.”
- 999 is compliant but not recommended since the incoming transaction was syntactically correct. If the 999 is used, the value returned in IK304 should be “2 – Unrecognized segment” pointing to the 2100D NM1 and 2100D DMG; other options such as “3 – Required Segment Missing” may also be used to advise that the 2100D NM1 and 2100D DMG were not sent where they should have been (2100C).
It is highly encouraged that the information source represent in their companion guide the information source’s support of 2000D-dependent-loop-level inquiries, including what submitters of the 270 should expect if the submitters send the 2000D loop when it is not supported by the information source.