Is an information source (payer) allowed to reject a 270 eligibility request transaction when the information receiver (provider) includes a Federal Taxpayer's Identification Number (TIN) in addition to the required National Provider Identifier (NPI)? Consider a Loop ID-2100B fragment like this.
NM1*1P*2*PROVIDER*****XX*0000000000~
REF*TJ*000000000~
With the REF segment present, the payer in question rejects the request. When the REF segment is removed, the payer returns a valid 271 response. It seems like a standards violation to reject the transaction just because a TIN is included. If they do not use the TIN, I think they should just ignore it rather than treating it as an error.
Some information sources (payers) are returning 271 responses containing error AAA03 = "43" (Invalid/Missing Provider Identification) when the 270 request includes both a provider NPI in Loop ID-2100B NM1 and a provider tax ID in Loop ID-2100B REF.
005010X279A1 does not prohibit additional Information Receiver information that may assist the Information Source in providing eligibility, coverage, and benefit details to the Information Receiver. Unless explicitly identified on the code value’s note (such as with SY – Social Security Number “The social security number may not be used for any Federally administered programs such as Medicare”), a rejection would be a violation of the REF segment situational rule “If not required by this implementation guide, may be provided at sender’s discretion, but cannot be required by the receiver.” [Emphasis added.] Rejection of a transaction for including additional information, such as a Federal Tax Identification Number or Prior Identification Number in the REF, may also cause abrasion to the provider if this information is necessary to include to seamlessly provide a response to a provider without resorting to alternate means to obtain the information (such as a phone call).
Regardless of the presence of an NPI in NM109, the REF segment could be used for other business purposes. It is designed to be allowed in conjunction with an NPI in NM109, or any other valid value in NM109. If the NPI is sent in 2100B NM109, the data sent in 2100B REF may not be used in lieu of the NPI to identify the provider, but may be used in addition to what was sent in NM109. If the information receiver sends, at their discretion, additional data in REF to support or supplement their NM109 identifier, it is up to that information receiver to determine what values they want to send, as long as it does not conflict with the 270/271 TR3.
With that, the information source may consider updating their companion guide identifying what valid REF values are used in the eligibility and benefit inquiry processing by the information source in addition to NM109.