Martin, My apologies for mis-using the term non-par (non-participating) when I truly did mean unknown.....I think some of the scenarios posted today describe this potential circumstance.
And by no means did I have say that a payer has to adjudiciate every claim received. Only that there is the potential to receive a claim from an unknown (to you) provider and that you cannot reject it out of hand. You at least have to take it in through your electronic mailroom and then decide what to do with it the same as you would have to do with a paper claim that hit your paper mailroom. This is where the TA1 segment could be used since of course, your EDI system won't recognize the ISA sender (or perhaps it could, if the sender was a clearinghouse with which you already do business and the provider isn't known until you peel back the transaction.) In that case, what do you plan to do? Rachel -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Wednesday, May 29, 2002 2:31 PM To: [EMAIL PROTECTED]; [EMAIL PROTECTED] Subject: RE: TA1 responding to non-participating health care providers Rachel, I'm thinking we have a simple misunderstanding of the terms "participating" and "non-participating". There is a difference between "unknown" and "non-participating". When you say "non-participating", do you mean it to indicate the provider's relationship with us as a submitter/receiver of standard transactions? >From my perspective, it is a long-standing industry term used to reference to the provider's contractual status with us as a plan. Their par(ticipating) or non-par(ticipating) status dictates reimbursement rates for certain plans/services and in many cases, who gets the check/Explanation Of Benefits. Given the standard usage for this term, I totally agree with you on the first three of your points. For item 4... We do anticipate receiving data from both par and non-par providers and processing/adjudicating those claims. If we receive claims from providers we can't identify or discern from what was received, they are not/will not be adjudicated whether they are received on paper or via EDI. Additionally, we reserve the right to not load data into our system that is coming from a submitter (which may be a provider) we don't know. And 5... We process it (provided we can identify the provider). _____ Martin A. Morrison -----Original Message----- From: Rachel Foerster [mailto:[EMAIL PROTECTED]] Sent: Wednesday, May 29, 2002 9:15 AM To: [EMAIL PROTECTED] Subject: RE: TA1 responding to non-participating health care providers Martin, Not to belabor my point, but the point I was trying to make is this: 1. It is potentially possible for a payer to receive an electronic claim from a non-participating provider 2. The payer cannot refuse to receive the claim 3. The payer is not obligated to process/adjudicate the claim 4. The payer, in my opinion, should anticipate the potential for receiving electronic claims from unknown providers and have a procedure for dealing with them 5. This process would be no different than what happens today if a payer receives a paper claim from a non-par provider....what do you do with it? Rachel -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Tuesday, May 28, 2002 8:16 PM To: [EMAIL PROTECTED]; [EMAIL PROTECTED] Subject: RE: TA1 responding to non-participating health care providers Rachel, I was afraid I'd be misunderstood. Let me address the points you raise, as I see them, in the order you present. I'm NOT saying, under HIPAA, that ANY payer has the option of not accepting a valid 837 based on the provider's non-participation status with said payer. We did have a policy like that some years ago. I believe some other payers may still. It was better for the bottom line to take in as many receipts as we could via EDI, so we dropped that restriction. We have NO intention of restricting submission of claims to participating providers. Our TPA's will not include any restrictive clauses not allowed in §162.915. We are writing our processes to the IG's trying to allow for as much flexibility on the submitters part as possible by including a lot of new business intelligence logic. We will only be including requirements that, if not met, will cause the transaction to be unprocessable by us. While these requirements (primarily codes) are specific to the HIPAA IG's, they correlate directly to elements contained in a paper submission. Bad data is bad data. If a covered entity wishes to conduct a standard transaction with us, we will accommodate their request, set them up and take their data or, if the transaction is an outbound transaction like the 835, we will start routing the data to the portal identified during the set-up. Their claims generation and accounts receivables may not be on the same platform or use the same transmission medium. We are not, in any way discriminating against submitters who want to conduct standard transactions. We have no intention of violating any clauses under §162.925. The closest thing we have here the necessary *adversity* of bullet "(2)": (Allowing us to set-up the submitter in our system in order to reliably conduct the transaction(s)). There has to be some reasonable thought applied to all of this. Certain things are just understood under HIPAA. Certain questions are never asked. Like... If we wished to do away with paper Explanations Of Benefits in favor of HIPAA-standard 835's, must all providers we process a claim for be able to receive an 835? I don't want to see this whole thing revert back to business as it has been done in the past and welcome the automation possibilities available to all of us under HIPAA. We should have been able to do all of this long ago without federal mandates, but we didn't. If we assume, now, that it's just a matter of opening all the spigots, I'm afraid we'll all drown. _____ Martin A. Morrison -----Original Message----- From: Rachel Foerster [mailto:[EMAIL PROTECTED]] Sent: Tuesday, May 28, 2002 4:49 PM To: [EMAIL PROTECTED] Subject: RE: TA1 responding to non-participating health care providers Martin, I don't share your perception that a payer can choose **not** to receive an electronic claim from a non-participating provider. I haven't seen anything in the statute or the electronic transaction rule that gives a payer the option of **not** receiving a HIPAA electronic transaction from a non-par provider. If you get them on paper today, you can and should anticipate getting them electronically in the future. Functionally, this is no different than a claim or other transaction on paper coming in through your company's mailroom or appearing on your fax machine. Furthermore, there is NO requirement for a trading partner agreement under HIPAA. § 162.915 Trading partner agreements. A covered entity must not enter into a trading partner agreement that would do any of the following: (a) Change the definition, data condition, or use of a data element or segment in a standard. (b) Add any data elements or segments to the maximum defined data set. (c) Use any code or data elements that are either marked ''not used'' in the standard's implementation specification or are not in the standard's implementation specification(s). (d) Change the meaning or intent of the standard's implementation specification(s). If you strongly disagree with this potential scenario and whether or not your organization is obligated to at a minimum receive the electronic interchange and enclosed transaction(s) in through your electronic front door then I strongly recommend that you consult with your corporatation's legal counsel on the issue. >From the Electronic Transaction Final Rule: § 162.925 Additional requirements for health plans. (a) General rules. (1) If an entity requests a health plan to conduct a transaction as a standard transaction, the health plan must do so. (2) A health plan may not delay or reject a transaction, or attempt to adversely affect the other entity or the transaction, because the transaction is a standard transaction. (3) A health plan may not reject a standard transaction on the basis that it contains data elements not needed or used by the health plan (for example, coordination of benefits information). (4) A health plan may not offer an incentive for a health care provider to Rachel Foerster Principal Rachel Foerster & Associates, Ltd. Professionals in EDI & Electronic Commerce 39432 North Avenue Beach Park, IL 60099 Phone: 847-872-8070 Fax: 847-872-6860 http://www.rfa-edi.com -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Tuesday, May 28, 2002 5:23 PM To: [EMAIL PROTECTED] Subject: RE: TA1 responding to non-participating health care providers Whoa!, Bill... You make it sound as if payers will be obligated to open their gateways, carte blanch, to any who wish to direct a file our way. While there may, in the past, for some payers, have been requirements that a provider must be "participating" in order to submit their claims electronically or otherwise capitalize on their EDI investment(s), that in no way means that we have to take in a file from entities we haven't entered into a Trading Partner Agreement with and set up in our system(s)(participating or not). If a provider were to unilaterally determine how to route data to us and get it wrong, it would increase the chance that we might be receiving another carriers information in error. There is also the issue of our not being able to process their information or inquiry as certain basic identifiers (part of the TPA) were not used or used correctly. I know it flies in the face of admin simp., but, until all the identifiers are finalized, we will have TPA's that look a lot like what we have today. If I have missed something in this thread or misinterpreted your intent, please accept my apologies in advance. _____ Martin A. Morrison Project Management Consultant HIPAA Implementation/Coordination Blue Shield of California 4203 Town Center Bl., Ste. D1 El Dorado Hills, Ca 95762 Ph: (916) 350-8808 Fx: (916) 350-8623 -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Tuesday, May 28, 2002 2:59 PM To: WEDi/SNIP ID & Routing Subject: TA1 responding to non-participating health care providers Just one more reminder - this time from the EDI-L mailing list - that we have to keep in the back of our mind something almost no other industry has wrestled with in EDI before: Unsolicited Transactions, à la Open-EDI, from non-participating providers. Payers will have to be prepared for taking in anything coming along from providers - if they would have taken paper before, they can't put roadblocks up discriminating against the equivalent Federally mandated HIPAA standard transactions! Not only will they have to make available an open portal for receiving electronic claims and eligibility inquiries (advertised in our Healthcare CPP Registry), but they will have to make sure their translators can accommodate ISA senders they've never seen before. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Rachel Foerster" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Tuesday, 28 May, 2002 01:32 PM Subject: RE: [EDI-L] TA1 On the other hand, the TA1 may become a useful/important ack in health care under HIPAA since it's entirely possible that a payer/health plan/insurance company could receive an unsolicited interchange containing health care claim transactions from non-participating health care providers. In this scenario, the translator won't know about the sender in advance, but the receiver needs to know it's received an interchange from an unknown sender and then take appropriate action. Rachel Foerster Principal Rachel Foerster & Associates, Ltd. Professionals in EDI & Electronic Commerce 39432 North Avenue Beach Park, IL 60099 Phone: 847-872-8070 Fax: 847-872-6860 http://www.rfa-edi.com -----Original Message----- From: DPR [mailto:[EMAIL PROTECTED]] Sent: Sunday, May 26, 2002 11:19 AM To: [EMAIL PROTECTED] Subject: [EDI-L] TA1 In my experience, I have never found anyone who wanted or cared about a TA1 segment. About all it says is roll call "I'm here'. There are quite a number of translators who don't even know what a TA1 is and choke if one gets through. So save your time and money and forget about the TA1. If the ISA/IEA is bad, you will never get a 997 in return. Dennis Robinson
