William, When a provider sends 3,654 claims, and one of them is bad... I don't think the providers are going to agree with the idea that it is OK to reject all of them because the one bad claim in the file. If the other 3,653 claims are HIPAA compliant, can the payer refuse them? Isn't the payer required to conduct the standard transactions?
Here is where the world of EDI and the world of business collide. It may be an invalid 837 because it is tainted by a bad claim... but is that what was intended when the Secretary adopted the 837? Kepa On Sunday 21 July 2002 10:32 am, William J. Kammerer wrote: > May I suggest that this thread be moved to just one or the other of the > WEDI/SNIP Business Issues or Transactions listserves? Cross-posting (on > the WEDI/SNIP listserves) runs counter to Zon Owen's SNIP Listserv Usage > & Etiquette Guidelines (2002-04-01) at > http://www.mail-archive.com/business%40wedi.org/msg00311.html. > > A recipient *may* reject an entire 837 transaction set if even only one > claim within is "tainted," but I doubt the law forbids more > "fine-grained" rejection. As Kepa noted, many of the semantic issues > may not be discovered until well into the back-end, long after the > transaction set has been translated. It may be difficult to "rollback" > thousands of correct "claims" within a single 837, for example, just > because the 3654th claim had a semantic inconsistency of the type Ellen > Falbowski mentioned: e.g., data from the CR1 Ambulance Transport > Information segment is missing when the payer finally discovers, deep in > the back-end, that an ambulance type Procedure Code was used. > > Since the 824 (004050X166) allows for selective rejection, the payer, if > she prefers, could accept all but the erroneous claim (items), or all > claims for the particular patient which contained the erroneous claim > line item, or the entire 837 - depending on what floats her boat > (technically and business-issue wise). The provider (or billing service > or CH) would have no call to complain if the payer were to reject the > entire 837 since it is, in effect, non-compliant; but at the same time, > he certainly would not object to the selective rejection of erroneous > claims - which obviously allows him to get paid for the clean claims, > however. > > The payer is not refusing to accept the standard transaction - the most > important part of the law, strongly emphasized throughout the TCS Rule. > And the provider still has not been given an artificial incentive to not > use the standard transaction, because he still hasn't gotten paid (for > the one invalid claim) even if the payer adjudicates the remainder of > the 837 (not because she is necessarily generous, but probably because > it's actually simpler for her). Everyone's happy: why should the HIPAA > Stasi get involved? > > William J. Kammerer > Novannet, LLC. > Columbus, US-OH 43221-3859 > +1 (614) 487-0320 > > ----- Original Message ----- > From: "Rachel Foerster" <[EMAIL PROTECTED]> > To: <[EMAIL PROTECTED]>; <[EMAIL PROTECTED]>; > <[EMAIL PROTECTED]> > Sent: Saturday, 20 July, 2002 11:30 AM > Subject: RE: When is a claim a standard claim? > > Ok Kepa....here's my take. Hopefully others will chime in. > > First, no where in the law or the regs is either the UB92 or HCFA-1500 > mentioned. Thus, I think we need to abandon thinking that DHHS was > looking for an equivalent in another standard format. If DHHS just > wanted a simple (!!!???) claim transaction, then why not just adopt > these two formats and be done with it. > > Second, since DHHS adopted the X12 837 "transaction set" as the > standard, I would have to assume (I know...that's a risky thing to > do!!!) that it did so knowing that the 837 is actually a container for > one or more claims. > > Thus, if any portion of what's in the container fails compliance, the > entire container is "tainted" as you say and must be rejected. This is > the position I've maintained for quite some time and I still believe > it's the appropriate way to go. For example, if the 837 container holds > only one claim that fails compliance, the entire 837 must be rejected - > container and all. The same would be true for a 270 containing inquiries > for multiple individuals, and also the 276 and a 278. I don't think we > can have one rule for the 837 transaction set and a different one for > the others. Furthermore, it's my opinion that any covered entity > conducting a non-complying transaction is subject to penalties under the > law, there needs to be much more black/white decision points (after all, > computers only think in terms of on/off, true/false) that can then be > embodied in program logic. It's all of this interpretative stuff that > causing all the heartburn now as it is. > > Rachel > RFA, Ltd. > > > > 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. > > -- This email contains confidential information intended only for the named addressee(s). Any use, distribution, copying or disclosure by any other person is strictly prohibited. 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.
