Hope
I'm sorry to disagree but I don't think the 997 is intended to handle this kind of problem. The 997 is used for syntactical errors not business problems of this nature. If a provider asks for a pre-determination of dental benefits and uses the correct elements/codes to do so there is no syntax error on their part. The pre-determination of dental benefits transaction is the same transaction as the dental transaction (004010X097) so you can't reject it saying you don't take those transactions (unless you don't take dental at all).
If you look at the 997 rejection codes at any level the messages are limited to things like:
Unrecognized segment ID
Unexpected segment
Mandatory segment missing
Loop Occurs Over Maximum Times
Segment Exceeds Maximum Use
Transaction Set Not Supported
Number of Included Segments Does Not Match Actual Count
etc.
Because there is no syntax error, there is no way you can use the 997 to tell a provider that you do not do pre-determination of benefits.
Jan Root
Hope Furtado wrote:
Jim,I recommend the use of the 997 Segment with an error message on the at
the Subscriber level indicating that you do not do predetermination of
benefits. I copied the following from the 837 Dental Implementation GuideFunctional Acknowledgment, 997
The Functional Acknowledgment Transaction Set, 997, has been designed to
allow
trading partners to establish a comprehensive control function as a part of
their business exchange process. This acknowledgment process facilitates
control
of EDI. There is a one-to-one correspondence between a 997 and a functional
group. Segments within the 997 can identify the acceptance or rejection of
the functional group, transaction sets or segments.Please contact me if you want to discuss this further.
Hope Furtado
Corporate Information Architect
TM Floyd & Company
(800)780-1170 ext 129
[EMAIL PROTECTED]> -----Original Message-----
> From: J.G. [SMTP:[EMAIL PROTECTED]]
> Sent: Tuesday, January 15, 2002 8:38 PM
> To: [EMAIL PROTECTED]
> Subject: Predetermination of Dental Benefits
>
>
> Our plan includes both medical as well as limited dental coverage. We do
> not do any predetermination of benefits today. If a provider calls in we
> tell them we don't predetermine benefits. If they send in a paper form we
> respond with a form letter telling them we don't predetermine benefits.
> If
> they ask specific questions on the phone, they may get some additional
> information, but nothing that should be close to an actual
> predetermination.
>
> The 837 Dental Claim transaction allows for a predetermination request.
> The
> 835 Remittance Advice allows for a response. However, I don't see a way
> to
> indicate that we don't perform predeterminations. Is there a way to do
> this
> in the 835, or is there another way to respond to this?
>
> Jim Griffin
> Business Systems Analyst
> CNA
>
>
>
>
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