Out on EDI-L, while discussing the open-EDI aspect of Healthcare - you know: claims coming in from unknown or non-par providers - folks are sharing their ailments as part of their stories. I won't do that here, as I save those stories for my neighbors on the plane. But suffice it to say, a recent "provider" of mine was the OSU Dental Faculty Practice (part of The Ohio State University College of Dentistry). The nice lady there with whom I discussed the bill said Anthem (the local BC/BS to which I subscribe) doesn't "talk" to OSU Dental Faculty Practice. I guess that's another way of saying they're "unknown," though I thought everyone knew who OSU was.
Anyway, OSU can send the claim to Anthem (paper, electronic, or through a billing service - I have no idea), but Anthem will not respond to them at all. Instead, she warned me, Anthem will send me a (paper) EOB and possibly a check. A couple of points are manifest in this story: (1) for my own "administrative simplification," OSU graciously agreed to submit a claim on my behalf; (2) at least Anthem deigned to take a claim - I can picture them holding their nose all the while - from the "unknown" OSU on my behalf; and (3) the check, if any, would be paid to me, the subscriber. This makes perfect sense, and conforms to my notion how claims and payments are handled for out-of-network (or is OSU "unknown"?) providers: payments should only be made to folks with whom the payer has a contract - in this case, me, since OSU is, well, "unknown". HIPAA does not require that Anthem pay the "unknown" OSU. It would have been nice if Anthem were to send an EOB to OSU, also - but not critical. Since Anthem is not paying OSU, there's no need for 1099s - solving Bruce's problem of reporting "unknown" provider income to the IRS. In the electronic analog of this story, the payer will have to accept standard 837s from the "unknown" OSU. The payer took OSU's paper claim; the law is clear that it will also have to take a file formatted according to the HIPAA IG. Which leads to the need for the Healthcare CPP registry: (1) OSU would have to have some (easy) means of finding Anthem's (free) electronic portal for submitting standard transactions, and (2) Anthem would need some way to find OSU's portal for returning responses (technical acknowledgements, like the TA1 and 997, and application acks like the 835 EOB). William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Bruce T LeGrand" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Cc: <[EMAIL PROTECTED]> Sent: Thursday, 30 May, 2002 08:52 AM Subject: RE: TA1 responding to non-participating health care providers Hello Rachel, What we will do is return a response to the submitter, depending on if it is an unknown trading partner or an unknown provider within data from a known trading partner. We will reject a transaction from an unknown trading partner. We will front end deny an unknown provider. We have many obligations related to paying providers. Working an unknown is not one of them. And I did not see anything in the rules requiring us to do so. A provider is not our customer, but potentially a trading partner. We have the liability of properly reporting income to the IRS and state income boards for payments to that provider. We will insist that they become known, not necessarily participating, to us before accepting their claims. ------------------( Forwarded letter 1 follows )-------------------- Date: Wed, 29 May 2002 16:43:36 -0500 To: [EMAIL PROTECTED] From: Rachel.Foerster[rachelf]@ix.netcom.com.comp Sender: [EMAIL PROTECTED] Reply-To: [EMAIL PROTECTED] Subject: RE: TA1 responding to non-participating health care providers 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
