We shouldn't get all "wrapped around an axle" on this "financially responsible party" business. As I described yesterday, if the payer is using a clearinghouse as his inbound portal, his own ID (perhaps even a proprietary CH-assigned ID) will probably appear on the ISA. I don't know what CHs require on the ISA receiver field for aggregated claims appearing in a single 837, but it's probably not that of the "financially responsible party" since there would be many such parties to whom claims are being made (in the single 837).
Actually there's nothing keeping *both* the provider and the payer from using proprietary formats or NSF, even under HIPAA. If there's only one CH between them, as long as the CH converts (or is capable of converting) the data to and from the standard HIPAA formats for at least a millisecond, all is okay. I think anything going *between* separate clearinghouses has to be standard transactions, though. William J. Kammerer Novannet, LLC. +1 (614) 487-0320 ----- Original Message ----- From: "Dave Minch" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Friday, 12 April, 2002 04:20 PM Subject: When is a CH a payer, or provider, for that matter? 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
