Dawn - I'm not aware of any HIPAA-approved, (HHS/X12N/DSMO) distinction between a clean claim and a clean transaction. I'm also not aware of the 837 IG's making that type of distinction.
An FAQ out on the DHHS Admin Simp website states:
If a health care provider electronically conducts a non-compliant
transaction (transmits an old National Standard Format or a proprietary
format) directly to a health plan after the transaction regulation
compliance date, and the health plan accepts and processes the
non-compliant transaction, who is in violation of the regulation? Is it the
health care provider or the health plan?
Does the acceptance and processing of a non-compliant transaction by a
health plan from a health care provider constitute a violative trading
partner agreement between the health plan and the health care provider?
(Embedded image moved to file: pic09322.gif)11/2/2001:
If a health care provider electronically conducts a non-standard
transaction with a health plan after the transaction regulation compliance
date, the health care provider and the health plan are both out of
compliance. Section 162.923(a) of the rule requires a covered entity
conducting an electronic transaction for which a standard has been adopted
with another covered entity to conduct it as a standard transaction.
If the health plan by agreement required the health care provider to
conduct non-standard electronic transactions, such agreement would not by
its terms violate section 162.915. However, if either party were to abide
by the agreement, they would be out of compliance with section 162.923(a),
for the reason stated above.
This FAQ talks about compliant and non-compliant TRANSACTIONS. In X12
parlance a transaction is EVERYTHING bounded by the ST/SE. So, it appears
to me that one interpretation of this FAQ is that it would inappropriate
(illegal?) for a Payer to accept a batch 837 transaction that did not
comply with the IG...even if that error could be isolated to a single claim
within that batch. It is my understand that the entire batch is the
Transaction.
Catherine Schulten
Sybase, Inc
6550 Rock Spring Drive
Suite 800
Bethesda, MD 20817
W: 301-896-1467
C: 703-338-6955
[EMAIL PROTECTED]
To: [EMAIL PROTECTED],
[EMAIL PROTECTED]
07/22/2002 cc:
12:58 PM Subject: Re: When is a claim a standard
claim?
Responding from a physician based level, as well as a patient, this
discussion about when to pay and whether or not to reject an entire batch
of individual claims based upon one noncompliant element of one claim
within the batch seems to have one simple answer. The industry is well
used to sending and receiving batches of multiple claims and sorting the
multiple claims into acceptable and unacceptable for some reason. I fail
to see the difference here.
Most medical practices batch their claims daily to insurers, and any
disruption of the orderly handling of that batch from submission to payment
is costly in terms of resources to both sides. It only makes sense to
allow "clean" claims to continue through the process and reject only
incomplete claims, without rejecting a batch full of perfectly appropriate
and compliant claims. That would seem to be the only solution that is
consistent with the original philosophy behind the HIPAA regulations.
If there are no regulatory explanations developed supporting rejection of
individual claims for noncompliance, rather than full batches, I would
expect that the general marketplace would enforce that solution anyway. In
this era of public and private entities monitoring physician/payor
relations and the ultimate effect disruptions in those relations have on
patients, it behooves us all to maximize the benefits of the HIPAA
regulations.
Dawn
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