I still have a question about whether we must use the 835 to
handle our Capitation and
PIP (Provider Incentive Payments) payments to our providers.
So am sending it to the
listserve with some additional details.
The Finalized Transaction Regulations page 50314 state that:
"With respect to health plans, a health plan is required to
have the capacity to accept and/or send (either itself, or by hiring a
health care clearinghouse to accept and/or send on its behalf) a standard
transaction that it otherwise conducts but does not currently support
electronically."
That's saying that we (as a Health Plan) need to support all
Standard Transactions electronically. Up to here I think we're all in
agreement.
To define what is covered under the 835 as a Standard
Transaction we need to read page 50371 Subpart P-Health Care Payment and
Remittance Advice.
"Sec. 162.1601 Health care payment and remittance advice
transaction. The health care payment and remittance advice transaction is
the transmission of either of the following for health care:
(a) The transmission of any of the following from a health
plan to a health care provider's financial institution:
(1) Payment.
(2) Information about the transfer of funds.
(3) Payment processing information.
(b) The transmission of either of the following from a
health plan to a health care provider:
(1) Explanation of benefits.
(2) Remittance advice.
Currently for CAP and PIP payments we do not send any
payment, processing information or information regarding transfer of funds
to our provider's financial institution. Furthermore, within the 835
Implementation guide(IG) it states that we can continue to use paper checks
as a payment mode. It would be in the Trading Partner agreement. So that
rules out section (a).
Section (b) states that if we send either an EOB or
Remittance Advice to the provider it must be done as an 835. See definition
below of a Remittance Advice as copied from the 835 IG:
"The 835 is intended to meet the particular needs of the
health care industry for the payment of claims and transfer of remittance
information. The 835 can be used to make a payment, send an Explanation of
Benefits (EOB) remittance advice, or make a payment and send an EOB
remittance advice from a health care payer to a health care provider, either
directly or through a DFI.
As a remittance advice, the 835 provides detailed payment
information relative to a health care claim(s) and, if applicable, describes
why the total original charges have not been paid in full. This remittance
information
is provided as "justification" for the payment, as well as
input to the payee's patient accounting system/accounts receivable (A/R) and
general ledger applications."
In both paragraphs, the IG talks about payment of claims.
Our CAP and PIP payments are not claim payments, or EOBs or Remittance
Advice, which I think, rules out section (b).
Based on the information outlined above, since our Cap/PIP
payments do not meet the criteria for either section (a) or section (b), I
think they do not meet Subpart P of the Final Transaction Regulation and we
can continue to handle on paper as we do today.
Am I totally off, is there any documentation that would
support requiring CAP/PIP payments as a standard transaction?
Appreciate your help with this question.
Sandy Brightly
Aetna
Phone 973-716-3858
e-* [EMAIL PROTECTED]
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