PH53460: PROBLEMS WITH SITUATIONAL RULES FOR CLAIMS WITH POST-PAYMENT RECOVERY

APAR status

• Closed as program error.

Error description

• The following situational requirement appears in the TR3
  documents for 005010X222A1, 005010X223A2, and 005010X224A2
  claims:
  
  2320 AMT01="D" is required when 2010AC is used
  This requirement appears on the 2320 AMT Coordination of
  Benefits Payer Paid Amount Segment.
  
  There are three HIPAA Compliance Check Type 4 Rules that are
  used to enforce the situational requirement for 005010X222A1,
  005010X223A2 and 005010X224A2 claims that applies to the 2320
  AMT Coordination of Benefits Payer Paid Amount Segment when
  the claim is a Post-Payment Recovery Claim:
  
  34876 837I 2320 AMT01="D" is required when 2010AC is used
  34880 837D 2320 AMT01="D" is required when 2010AC is used
  35090 837P 2320 AMT01="D" is required when 2010AC is used
  
  The HIPAA compliance check generates a 999 IK3 segment that
  indicates the 2010AC NM1 segment is missing with an I6 error
  code for Implementation Dependent Segment Missing.  The missing
  2320 AMT with AMT01="D" is not reported in the 999.
  
  AK2*837*00001*005010X224A2~
  IK3*NM1*12*2010*I6~
  IK5*R*I5~
  
  The TR3 documentation describes the following:
  
    The 2010AC is "Required when willing trading partners agree to
  use this implementation for their subrogation payment requests."
  and "...may only be used when BHT06 = "31".)
    BHT06 = "31" or Subrogation Demand code "is only for use by
  state Medicaid Agencies performing post payment recovery
  claiming with willing trading partners."
    2320 AMT with AMT01 = "D" is "Required when Loop ID-2010AC is
  present. In this case, the claim is a post payment recovery
  claim submitted by a subrogated Medicaid agency."
    "When Loop ID-2010AC is present, this is the amount the
  Medicaid agency actually paid."
  
  The interpretation is that every 2300 Claim Loop within the
  transaction set must have [at least] one 2320 Loop where the
  Other (COB) Payer has paid the claim.
  

Local fix

• ITXCQ - ITX00061825
  CN / CN
  Circumvention: None
  

Problem summary

• Users Affected:
  IBM Transformation Extender Pack for Healthcare HIPAA
  
  Problem Description:
  HIPAA Compliance Check Situational Rules for Claims with
  Post-Payment Recovery (AMT*D checks when 2010AC loop present)
  
  Platforms Affected:
  ALL
  

Problem conclusion

• New Ruletype R54 added to hcsvu, and new rules 60366-60371 added
   to properly check for other payer loops and an AMT*D present in
   one of those loops for each claim when 2010AC present.
  
  Applies to:
  Healthcare Pack HIPAA 10.1.0, 10.2.0, 10.2.1
  
  Fixed in the next service packs and releases.
  
  To obtain the fix for this APAR:
  
  To see if the next service pack or product release is available,
  check the IBM Transformation Extender Downloads page:
  http://www.ibm.com/support/entry/portal/product/other_software/t
  ransformation_extender
  
  If the service pack or product release is available, download it
  from Fix Central:
  http://www.ibm.com/support/fixcentral/
  
  If the service pack or product release is not available and you
  require the APAR fix immediately, request a Limited Availability
  Interim Fix (LAIF) by opening a PMR:
  http://www.ibm.com/support/servicerequest/Home.action
  
  Prior to version 9.0.0, IBM Transformation Extender was called
  IBM WebSphere Transformation Extender.
  

Temporary fix

Comments

APAR Information

• APAR is sysrouted FROM one or more of the following:

• APAR is sysrouted TO one or more of the following:

Fix information

• Fixed component name

  ITX

• Fixed component ID

  5724Q2300

Applicable component levels