If anybody were thinking we would come up with a scheme whereby you could put a plan ID into an ISA (which you can't, because the Interchange ID Qualifier can only address carriers or entities addressable by the DUNS or EIN), and auto-magically the interchange would end up at the appropriate place (the repricer for claims, or the Third Party Administrator for eligibility requests), then (1) that would be neat, and more importantly (2) it would be really, really hard to do.
I think if you want to have an 837 go to a particular repricer, you're probably going to have to explicitly put the repricer's identifier (what is that? - a DUNS, an EIN?) in the ISA receiver field. And, likewise, if you want a 270 to end up at a particular Third Party Administrator, I suppose that TPA's identifier will have to appear in the ISA receiver field. How is this done today using X12 through Clearinghouses? - what's expected in the ISA (and perhaps the GS)? What are we expecting out of the auto-routing capabilities of the electronic Trading Partner Agreement? Even if you had an e-TPA organized by plan, how would you locate it via Kepa's DNS "directory," which is organized by entity (e.g., payer)? You would have to know ahead of time which payer handles your plans before you could find the payer's e-TPA for locating the EDI front-doors, wouldn't you? What happens when the employer directly manages its self-funded plans without the assistance of a Third Party Administrator? How could standard transactions be addressed? If the DUNS were used through a VAN, could claims end up going to the same place as supply chain stuff? Is this where the DUNS+4 would come in? - to address the EDI gateway specifically at the HR department? What am I missing here? How does a CH do it? Help me out here. I'm out of my element. Dave Minch mentioned "Re-discovery," which I took to mean: how do you figure out whether the electronic Trading Partner Agreement has been updated? This could be done using a date-time stamp in the XML file for the e-TPA itself, or in its filename, pointed to by Kepa's DNS "directory." Or maybe we could place something (a serial number?) in the DNS node TXT record, which supposedly is propagated to all local name servers on a regular basis - then without having to retrieve the XML file, you could still tell whether anything has possibly been changed in the e-TPA. This is a problem to put on the "To-Do" (i.e., Rachel's requirements) list. So many questions. So little time. And whatever white paper we come up with will be in really sorry shape if we don't start getting some answers and feedback! William J. Kammerer Novannet, LLC. +1 (614) 487-0320 ----- Original Message ----- From: "Dave Minch" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Cc: <[EMAIL PROTECTED]> Sent: Wednesday, 20 February, 2002 08:23 PM Subject: Repricers, Reviewers, Third Party Administrators, etc. -- why we (providers) are concerned William, Noticed that I never answered your questions below, so I thought I'd take a minute & do so. When everything was fee-for-service, the world was simple - then HCFA decided to contract for certain services from certain providers, and to only pay "schedule" rates for other services. The flood gates are now wide open, and we have nearly as many health plans as we do employers represented in our databases. The carriers offer "specialized" plans and there are no guidelines on how these coverage agreements are structured - its truly a boutique business. The carriers sell the plans to employers, who turn around and offer the coverage to their employees - larger employers offer several different coverages, depending on the employee's needs. They (carriers, large self-insured employers, HMOs) then come to our front door (some thru the back door) and negotiate with us to be a contracted provider to perform some or all of the services they are selling at the other end. Along with these plans came another cottage industry - third party administrators (TPAs) - who sell their services to employers and carriers - they contract to perform lots of different services including claims review, claims repricing (taking the provider's charges and "re-pricing" them to reflect contract agreed charges), eligibility & benefits checking, etc. Further, if the plan is capitated, they perform other services related to lifetime benefits and adjudication on behalf of the plans. There are numerous situations where more than one TPA can be in the mix - e.g. a professional repricer before the plan administrator, and even a separate reviewer. They can be in any sequence, though the repricer is usually the first stop for claims if one is present. The only good news is that usually (but not always) the TPAs can figure out amongst themselves where to send the claim next in the sequence because they only deal with a limited set of contracts. The kicker is that these "third parties" usually get inserted into the mix because neither the employer nor carrier want to be burdened with figuring out the nuances of the ridiculous contracts they are negotiating. So they contract with the third party, and then tell us that "for plan INS-xxxx, send the claim to RPCyyy, and request eligibility & benefits from TPAzzz". So, it ends up being our problem to determine where to send claims and address inquiries. I have no doubt that this situation will continue with EDI, so having a separate set of addresses by plan and transaction makes a lot of sense to me. This assignment is somewhat dynamic, however, and needs to be kept up to date by whoever is contracting for the coverage. These contracts are usually not long-term, and when they change, often the claim destination can change along with other contract terms. I'm still not sure I understand how we would ever go about determination that re-discovery is necessary, but i'm learning more every day... Hope this helps to explain some of it. Dave Minch T&CS Project Manager John Muir / Mt. Diablo Health System Walnut Creek, CA (925) 941-2240
