I'd like to see if we can get some clarification around the different business processes that occur before a HIPAA transaction occurs. This may help clear up many of our issues regarding routing, addressing and TPA's.
This is where I believe Rachel was trying to leverage the UML and business requirements gathering techniques to reduce the amount of misunderstanding about how things happen today. So, with that in mind. It appears that Routing and Addressing may be dependant upon the existence of some Trading Partner Agreement. Whether it be in writing or not - I would assume a verbal agreement to use the X12N standards is a form of a TPA (although I'm not a lawyer). Taking a simplified approach to understanding how identifiers are gathered/created (The IG covers much of this, and I'm sure we're all too familiar with this), but lets put it on the table: Provider is a Provider/Institution. Provider obtains License to Practice Plan obtains License to Insure Providers Participate/Register in Plan Provider requests/submits Electronic Billing Authorization Plan establishes TPA with Provider Sponsors Participate/Register in Plan Members Join (Individuals and Families) Sponsors notify Plan of new Members Members pay Plan Premium Member becomes Patient Patient visits Provider Provider requests Patient/Member Plan Eligibility Provider requests/submits Electronic Billing Authorization Plan establishes TPA with Provider Provider diagnose Patient Provider identifies Procedure Provider requests Procedure Authorization (from Patient and/or Plan) Provider services Patient Provider requests/submits Electronic Billing Authorization Plan establishes TPA with Provider Provider bills Member/Plan for Patient services Member may pay Provider for services Plan pays Member/Provider for services Assuming an Electronic transaction to a Plan: Provider submits electronic transaction to Plan (Different delivery/processing methods- CH, Re-Pricer, Third Party, fit here) Plan receives Transaction request Plan verifies ISA Submitter has Electronic Authorization Plan acknowledges request to ISA Submitter (Different delivery/processing methods - CH,Re-Pricer, Third Party, fit here) Plan verifies transaction (Provider and Member) identities Plan responds to transaction (Provider) request (Different delivery/processing methods - CH,Re-Pricer, Third Party, fit here) Provider receives Plan Acknowledgment and Response While I may not have gotten all the steps involved, clearly there are dependant, conditional and optional steps here. Also, throughout each step, information could be gathered that will determine the appropriate identifiers for routing or addressing of a given transaction, before the transaction is to occur. Eventually, we should be able to define the Authoritative Sources of the significant identifiers for addressing (hope I'm appropriately using the terms identifier and address). Once we begin defining sources of identifier information, we can then determine how to use or standardize those sources to assist in determining addressing. I would like to see this list flushed out into a UML that helps identify the process more clearly. I don't have any UML applications that would model this, so any volunteers? Regards, Ronald Bowron
