X12 team, I have a provider group who is able to submit 5010 encounter claims to Humana. However, they are sending the CN1 segment with an "05" that the encounter claim being submitted is a capitated claim. However, Humana does not require the CN1 segment to be sent, because we are getting these encounter claims compliant 5010 X222A2 and X223A2 transaction types.
The issue comes, where our clearinghouse Availity, is rejecting the CN1 back to the group telling them it is not required. When the group removes the CN1 the encounter successfully comes through. My question is, does this group have the right to require that my company accept the CN1 even though it is rejecting off of EDIFECS? Please advise.
The CN1 segment usage is defined as follows:
Situational Rule: Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send
TR3 Note: The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
If the situational requirement is not met as defined, the CN1 segment must not be sent. However, the decision to accept or reject any claim regardless of its compliance with any X12 Implementation Guide is a business decision of the receiver.