Interesting.
Coming to claims that are already in the system/application prior to HIPAA
switch being turned on, we may not be able to apply HIPAA edits for two
reasons : 1. Claims may have non standard code sets that may not pass
Level-5 HIPAA edits (code set validation) 2. The claim may be have come in
the non-standard format, so there is no need to apply Level-1 to Level-6
edits. Folks, please correct me if I am wrong.
Now, I have one question to the Group:
What are the different scenarios for processing claims after Oct 2003? I
have listed here some of them. Please add if I have missed anything or if I
am wrong.
Scenario-1 : Claims with standard code sets in X12 4010 format
Option : No problem as the HIPAA compliant application will be able to
handle it happily.
Scenario-2 : Claims with Standard codes in Paper format
Option-1: Accept, adjudicate and send Paper EOB. Only Level-5 HIPAA Edit in
the application.
Option-2: Send 835 ERA, if provider requests. (Make sure all minimum
required information is available for generating 835 as response to Paper
claim). Level-5 edit in the application and other HIPAA edits for 835 at the
outbound side.
Scenario-3 : Claims with non-standard codes in Paper format.
Option-1: Accept, cross walk, adjudicate and send paper EOB.
Option-2: Notify providers to stop sending claims with non-standard codes
from a cut-off date prior to HIPAA compliance date.
Am I missing anything ?
Thanks
Palani
Cognizant Technology Solutions
201-678-2772
-----Original Message-----
From: Winston, Mike K. [mailto:[EMAIL PROTECTED]]
Sent: Tuesday, May 21, 2002 7:46 AM
To: 'Dhandapani, Palani (Cognizant)'; [EMAIL PROTECTED];
'[EMAIL PROTECTED]'
Subject: RE: Date of service
Thanks,
I do not see how Hipaa can expect edits to be applied to a claim adjustment
when the original claim was processed before the edits were established.
Does Claim generation refer to the date the claim was generated by the
provider, if so then claims already in our system prior to the Hipaa switch
being turned on do not have to meet the Hipaa edits. Correct?
Mike Winston
Business Systems Analyst
Trigon ISD
Ph (804) 354-4521
Fx (804) 678-0452
[EMAIL PROTECTED]
This message, including files attached to it, may contain confidential
information that is intended only for the use of the ADDRESSEE(S) named
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you have received this message in error, please notify the sender
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> -----Original Message-----
> From: Dhandapani, Palani (Cognizant) [SMTP:[EMAIL PROTECTED]]
> Sent: Tuesday, May 21, 2002 10:15 AM
> To: Winston, Mike K.; [EMAIL PROTECTED]; '[EMAIL PROTECTED]'
> Subject: RE: Date of service
>
> There are two components here. Medical code sets and NonMedical code sets.
>
> For Non-medical code sets, the Data of service is the reference. So we
> should use the medical codes that are valid on the date of service.
>
> For Non-medical code sets, the date of Claim generation is the reference.
>
> Please refer to the following regulation:
>
> 162.1000
>
> (a) Medical data code sets: Use the applicable medical data code sets
> described in section 162.1002 as specified in the implementation
> specification adopted under this part that are valid at the time the
> health
> care is furnished.
>
> (b) NonMedical data code sets: Use the non medical data code sets as
> described in the implementation specifications adopted under this part
> that
> are valid at the time the transaction is initiated.
>
> Hope this helps.
>
> Thanks
> Palani
> Cognizant Technology Solutions
> 201-678-2772
>
>
> -----Original Message-----
> From: Winston, Mike K. [mailto:[EMAIL PROTECTED]]
> Sent: Tuesday, May 21, 2002 6:37 AM
> To: [EMAIL PROTECTED]; '[EMAIL PROTECTED]'
> Subject: Date of service
>
>
> I know this was discussed, but I want to confirm that opinions have not
> changed. When Hipaa is in effect we are planning on using the claims Date
> of
> Service to determine if the claim needs to be fully compliant or not,
> example: Claim was submitted prior to Hipaa live date with a "Homegrown
> code" the 835 goes out after Hipaa is implemented with the non-compliant
> code. or Claims that were not subject to any crossfoot edits prior to
> hipaa
> if adjusted will be sent out on the 835 but will not crossfoot.
>
> We are making the logic based on the claims date of service not the
> processed date. Any thoughts?
>
> Mike Winston
> Business Systems Analyst
> Trigon ISD
> Ph (804) 354-4521
> Fx (804) 678-0452
> [EMAIL PROTECTED]
>
> This message, including files attached to it, may contain confidential
> information that is intended only for the use of the ADDRESSEE(S) named
> above. If you are not the intended recipient, you are hereby notified
> that
> any dissemination or copying of the information is strictly prohibited.
> If
> you have received this message in error, please notify the sender
> immediately and delete the message from your system. Thank you.
>
>
>
>
>
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