Can a payer be required to utilize all available Member IDs in their search for Dual Eligible Plan?
Consider these possible payers: a commercial payer, Medicaid, and a Medicare Dual eligible payer. The commercial payer uses their own number as a primary search value or the Medicaid ID number when it is an MCO. There are a number of patients that are Medicaid/Medicare dual eligible for which another search option would improve likelihood in registration process. For patients enrolled in Medicare benefits with MBI, could we not require the use of all three numbers when the policy may cross 3 different payers?
MBI is key and directly associated with the member, as is the Medicaid number and the commercial payer number. All 3 are somewhere in a payer's system tied to the patient.
This is more of a business question than an X12 specification question, as the TR3 does technically allow for the return of other payer information using 2120C/D. See item 6 in Section 1.4.7.1 Minimum Requirements For Implementation Guide Compliance, which specifies the response requirements for when an individual exists within the information source’s system:
“Other payers or plans if known in 2120C/D. (Note: Do not return details of coverage or benefits associated with other payers or plans, the Information Receiver should initiate a separate 270 request to the other payer or plan to determine the level of coverage.)”
X12 does not define what an information source considers coverage or benefit details.
Outside of the front matter requirement expecting other payers or plans to be returned, if known, specifically in the case of coordination of benefits scenarios, the implementation guide does not add additional requirements that this must be supported, despite the technical specifications supporting this functionality in 005010X279A1. An organization will need to determine within their own controls what information is available for other plans, even if the plan is within their organization’s oversight, when the information is not directly linked to the information used on the 270, such as the submitted member ID.