Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules

XII. CAQH CORE 258: Normalizing Patient Last Name Rule

  1. In reviewing the rule, I could not find any statement on how hyphenated or apostrophized last names would be handled, e.g., O'Donnell-Griswold? Would it be just Odonnell? Or is this something which is or has been addressed in another CAQH CORE Rule?
  2. We have a situation in which some beneficiaries may have two last names as in the case of beneficiaries in Puerto Rico in which a married woman will keep her last name and add “de” as the prefix to her husband’s last name (e.g., Maria Garcia DeSanchez). Garcia is the maiden name and Sanchez is the married name. How does CAQH CORE propose the handling of patient last name in this situation?
  3. With regard to Section 4.2.2–Character Strings To Be Removed During Name Normalization, what recommendations does CAQH CORE have for instances where the last name contains concatenated last name + suffix? For example, with the patient name JAMES C POMP II, last name may be stored as “POMPII”. How can we tell if the last name should be “Pomp” And Not “Pompii” and strip the “II” by mistake? While the instance of a Jr./Sr. suffix can easily be identified, others such as “MD” and “RN” will be more difficult to identify as in the case of a name ending in “RN” like “BURN”). In most cases the last names are concatenated with suffixes and not in a separate field and not easily identifiable.
  4. If a health plan receives the subscriber ID number and the subscriber last name in the X12 270 inquiry, does the health plan have to use the subscriber last name or can they ignore the subscriber last name when processing the X12 270 Inquiry?
1. In reviewing the rule, I could not find any statement on how hyphenated or apostrophized last names would be handled, e.g., O'Donnell-Griswold? Would it be just Odonnell? Or is this something which is or has been addressed in another CAQH CORE Rule?

CAQH CORE 258: Last Name Normalization Rule Version 2.1.0 DOES require the removal of both the apostrophe and the hyphen in the O’Donnell-Griswold example cited. The normalized name would be ODONNELLGRISWOLD. Section 3.7 (3) lists the X12-designated “special characters” of the “Basic Character Set” and the list includes both the apostrophe and the hyphen. Section 4.2.1 of the rule then says “remove the special characters specified in §3.7 in the name element.”

2. We have a situation in which some beneficiaries may have two last names as in the case of beneficiaries in Puerto Rico in which a married woman will keep her last name and add “de” as the prefix to her husband’s last name (e.g., Maria Garcia DeSanchez). Garcia is the maiden name and Sanchez is the married name. How does CAQH CORE propose the handling of patient last name in this situation?

CAQH CORE 258: Last Name Normalization Rule Version 2.1.0 does not address this specific scenario. Since the characters “De” are not included in the specified set of character strings to be removed, any validation of the last name performed by the health plan would naturally be against what was submitted in the Last Name data element in the X12 270 request against what the health plan maintains in its eligibility system. This is outside the scope of the CAQH CORE Rule.

3. With regard to Section 4.2.2–Character Strings To Be Removed During Name Normalization, what recommendations does CAQH CORE have for instances where the last name contains concatenated last name + suffix? For example, with the patient name JAMES C POMP II, last name may be stored as “POMPII”. How can we tell if the last name should be “Pomp” And Not “Pompii” and strip the “II” by mistake? While the instance of a Jr./Sr. suffix can easily be identified, others such as “MD” and “RN” will be more difficult to identify as in the case of a name ending in “RN” like “BURN”). In most cases the last names are concatenated with suffixes and not in a separate field and not easily identifiable.

The CAQH CORE 258 Rule includes the character string “II” in the set of specified character strings to be removed during normalization (Section 4.2.2.) Additionally, the rule in Section 4.2.1 defines how to normalize the last name, to wit: “To normalize the submitted and stored last name remove all of the character strings specified in Section 4.2.1 when they are preceded by one of the punctuation values specified in Section 4.2.3 and followed by a space or when they are preceded by one of the punctuation values specified in Section 4.2.3 and are at the end of the data element and remove the special characters specified in Section 3.7 in the name element. If the last name as submitted and as stored is not delimiting the suffix using one of the specified punctuation values or store the suffix separately, the normalization logic will not remove the character string “II”. The CAQH CORE Rule does not specify HOW an entity must store a last name, but does make recommendations on this issue in Sections 4.1.1 and 4.1.2.

4. If a health plan receives the subscriber ID number and the subscriber last name in the X12 270 inquiry, does the health plan have to use the subscriber last name or can they ignore the subscriber last name when processing the X12 270 Inquiry?

The CAQH CORE 258 Rule does not require that a health plan use the patient’s last name in its search and matching logic for locating an individual within its systems. Further, the rule does not specify the search criteria used by a health plan (or information source) to identify a patient in its systems. That is, when the last name is not used in the health plan’s search/match logic – the rule does not apply – and if the health plan receives the patient's unique ID number in an X12 270 eligibility inquiry, it may use or ignore the name or other demographic data about the individual if not needed or used to uniquely locate that individual in the plan’s systems.