Is the service level HCR segment always required when the service level AAA segment is not present even when the decision for the service follows the decision at the Patient Event level? There is a contradiction in the specification for this particular case. The situational rule for the service level HCR segment indicates that this segment is only required if the UMO renders decision at service level. However, the TR3 notes for the service level AAA segment indicates that when the service loop is present, either AAA segment or HCR segment must be returned. Which one should we follow? Should we always return service level HCR segment if we send service loop data without AAA segment at that service loop?
The UMO rendered a decision on the request as Pended at patient event level, so it sends HCR*A4**0V~ at patient event level. The UMO rendered the same decision for the service loop which is not rejected. Should the UMO send the same HCR*A4**0V~ at service level inside the service loop, or should the UMO omit sending any HCR segment at service level even though there is no AAA segment in the service loop?
The service level response is only required when the UMO has reviewed the request at the service level, and the UMO renders a decision at both the Patient Event level and at the Service level, to provide service review outcome information and an associated reference number. There is guidance to return either the HCR or AAA at the Patient event and/or the Service Level – if there is a decision/rejection made at those levels and are being returned.
Related RFIs: 1302