If, as Rachel has suggested, many of the payers are actually going to contract with CHs as their "front door" for EDI (whether the CHs are subsidiaries or otherwise), then that CH's identifier could, in fact, be the identifier that the payer tells us (via the CPP or other manual method) to place on the claim (in the ISA). It would be assumed, in that situation, that the CH is acting on behalf of (is the agent for) the payer, and therefor represents "the financially responsible party" in its dealings with the provider.
In that case, the CH would have specific arrangements with the payer (a TPA), that could, in fact, specify conversion to a proprietary format (such as NSF) for transfer of the claim to the payer. As long as the claim is transferred from provider to the CH as an 837, the law is satisfied (as I read it), because the CH would be operating as the payer's agent. This is also true in reverse for the providers. Some billing software will be used by smaller providers to enter claims data, and will then transfer that data to a central location in a proprietary format (say, a "flat print image file"). The central location is the billing software's "hub" - just another CH in our view, but one with a special relation to the provider - it is the provider's "billing agent"). Again, the law is satisfied because the CH is the agent of the provider, and it communicates to payers via the mandated transaction set. One of the largest provider software suppliers in the country is planning on doing just that as their "answer" to making the software HIPAA compliant - and they are licking their chops at the millions of $$ to be made sending all those claims on behalf of the provider in that really difficult electronic format (and for only $.25 per claim - what a deal...). Have I misinterpreted the regulations? Anyone want to bet that these won't be the most common scenarios initially? Dave Minch T&CS Project Manager John Muir / Mt. Diablo Health System Walnut Creek, CA (925) 941-2240
