Change Request Detail
No.
1028
Date
9/2/2005
Submitter
Type of Request
Pertaining to more than one, or not sure
Status
DSMO Process Completed
Business Reason
An 4010X098A1 (claim) file gets created with a billing loop that looks like:

NM1*85*2*Name here*****24*111111111~
N3*address1*address2~
N4*city*st*zip~
REF*G2*2222222~

The claim goes through fine. I send over a 4010X093A1 (status) request for the claim. It allows for only one identifier for the provider:

NM1*1P*2*Name here*****SV*2222222~

The carrier doesn't want the carrier specific ID that we sent, they want the tax ID:

NM1*1P*2*Name here*****FI*111111111~

It is difficult to determine what the insurance carrier wants because they can make their own rules about what they want in the segment.

I suggest making the loops (aside the from the subscriber specific loops) the same across all transactions. The vendor should be able to create the same envelope, receiver loop, submitter loop, billing loop, etc. regardless of what transaction is being sent. This way the carrier can't say that they can't take a number here or there for a certain transaction, because they would be getting all the same information as was sent for the claim.
Suggestion
Make the loops the same across all transactions for submitter, receiver, billing provider, etc. loops.
DSMO Category
D
Recommendation
Disapprove. The DSMO supports the normalization of data across the multiple implementation guides to identify submitters, receivers, etc. Implementation of this request would require extensive analysis, industry consensus, evaluation of benefit vs. cost, and significant data maintenance to several transactions. The requestor is invited to attend X12 meetings and assist in standardization efforts.
Appeal Recommendation