Procella Helpdesk- There is a setting in the PBM configuration that decides whether to reject the claim with 06 - M/I Group ID when the group ID is not submitted in the claim
- If the 'require_group_id' flag is TRUE, then it's mandatory to have the Group ID field (301-C1) in the claim. The system will reject the claim if this field is missing.
- If the 'require_group_id' flag is FALSE, then the system will follow the below steps in the mentioned sequence to find a group to adjudicate the claim
*SBM stands for 'Submitted'
Step 1
If the submitted Group ID matches any external group ID in the PBM, then that group configuration will be used to further adjudicate the claim.
Sample Claim
699888D0B1DISCOUNT 1011518265628 20240406TEST AM04C2FMA-TESTMEMC1CMP09 C61C301C90CCTESTCDMEM2A123452BAL2DYG2YFOCOM001N5123N6456AM01C420230101C51CAPROCELLACBMEM4X00AM07EM1D21231211DE20210101E103D700002448354D61D33D530D82E71000DJ1ET2000G101EV123EU01DF1AM11D9100000{DU10{DQ100000{DC50{DX742EE350{HA0{GE0{HE000{DN00AM03DB1760637474EZ01DRROSALIA2KHUIGKUBKJB4EHUKHBIK2N262P48484962MHCHCHCHGPM562354962
Step 2
If step 1 fails (if the system is not able to identify a matching group in the PBM based on the submitted group ID), then the system tries to identify the group using the submitted plan ID (524-FO)
- Case 1 - If plan ID is available in the claim, then the system tries to find the Group based on Group Plan Association, if the system finds a single group then it's used for claim adjudication
- Case 2 - If plan ID is available in the claim, then the system tries to find the group based on the group plan association. If the system finds more than one Group, then the group is selected based on which group has this plan as the default Plan. If more than one group has this plan as the default plan, then the system moves to Step 3 to determine the Group.
- Case 3 - If plan ID is NOT available in the claim, then the system moves to Step 3 to determine the Group
Step 3
If the system is still not able to identify a matching group based on the submitted group ID and plan ID, then the BIN and PCN are used. There is a toggle in the group configuration to set it as the default group for a BIN and PCN. If the system still cannot find a group, then it moves to next step
Step 4
In the PBM configuration, there is an option to set a group as a default group. The system will use that Group to adjudicate the claim.
If NO group is set as default in the PBM configuration, then the claim gets rejected with 51-Non matched group ID