I am interested in hearing from other HMO's, PHO's, Mental Health Carriers and others who deal with either end of the global capitation environment.
1. If the HMO's globally capitate a Network, PHO or IPA and require that they return paid claims data, does that not meet the definition of encounter data? If you are a plan - are you therefore requiring it to be sent in the 837? If a provider are plan's asking you for the 837? If yes, 2. Have you thought about how to reconcile that the 837 captures little or no elements of the payment? and how have you reconciled this? 3. Assuming the issues in #2 can be resolved - How would the PHO or Network, who receives primarily paper 1500 forms or superbills from the docs be able to create a compliant 837 when these forms do not contain the required data elements of the 837? FYI - My interpretation of issue 1 is that yes, it meets the definition. Many of of Networks, however, disagree and have reported that other payers are not requiring this. I am trying to collect additional information how the industry views this scenario. To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=business and enter your email address. The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited.
