William: Some points about NJ HINT.
In answer to your question about how a non-par provider gets the "address" for a payer, one thing to note is that a provider does not have to be participating to use electronic transactions. I don't think HIPAA would allow a carrier to tie using standard Transactions to entering into a provider agreement for defined fees. So a non-par provider could still have a connection. Thus, if the provider in NJ wants to send a claim electronically to a NJ carrier, the provider will have to connect the same way any other provider would. Also, keep in mind that NJ HINT applies to NJ Providers submitting claims to NJ Carriers. Non-NJ carriers are not subject to HINT. So if a person is visiting from Montana, and their coverage is from Joe's HMO of Montana, then all bets are off. As for the unsolicited 277, the Regulation does require the use of this transaction by carriers. That is because NJ law requires carriers to acknowledge receipt of claims. The U277 was chosen by the Department over the 997 because the U277 can acknowledge specific claims, while the 997 can only acknowledge that a file was received. NJ's Department of Insurance felt this was an appropriate way to comply with the other NJ requirements for acknowledging claims. By the way, if one were to review state insurance laws in other states, I am willing to be real money that every state requires carriers to acknowledge receipt of a claim and possibly to send out updates if the claim is not going to be processed promptly. These requirements were generally adopted back in the days when carriers received claims from policyholders who had paid the claim and who was waiting for reimbursement. Legislators felt it was important for the carrier to acknowledge to the individual that the claim was received and being worked on. NJ is not unique in their requirements, they are just the first state to figure out how to apply those requirements to an electronic world. Also, to your questions about a carrier will interact with various providers, the HINT Regulation recognizes that some providers may not be able to receive this transaction, and some may not want to receive this transaction (for example, the provider's clearinghouse may charge a fee per transaction the doc doesn't want to pay). The Regulation permits the carrier and provider to mutually agree on an alternative means of notifying the provider in those instances. I don't know how this might lock a carrier into a clearinghouse contract, unless the carrier was not planning on building an unsolicited 277. Hope that helps. Ken Fody AmeriHealth HMO and AmeriHealth Insurance Co. of NJ -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Thursday, June 27, 2002 9:15 AM To: 'WEDi/SNIP ID & Routing' Subject: Re: Transactions Listserve: Unsolicited 277 in response to claim submissions Fortunately, as the assistant co-chair waterboy, I get to decide what's in or out of scope, unless over-ruled by the senior executive co-chair, Peter Barry. I'm sure the Unsolicited 277 (277U) is a fine transaction, and I have no beef with it. I'm not interested at this time in discussing its innards or business functions; though if I were, I agree with Dominic that X12N TG2 WG5 would be the appropriate venue for discussion. No, instead, I'm interested in the law's ramifications on identification and routing. It looks like the law provides plenty of incentives for the use of EDI in both making claims and receiving Front-End Acknowledgments. The law doesn't say "only if the provider has filed a bunch of paperwork with the payer." So, again, if a non-par provider needs to file a claim on behalf of the patient (which the law mandates), he may do it either with a paper claim or an 837. If he prefers an 837, to take advantage of NJ's more generous prompt-pay provisions with respect to EDI , how does he go about finding the "electronic address" of the payer? How does the payer know the provider's all set up to accept the 277U, or know where to send the acknowledgement? Is the provider locked into a CH arrangement in order to comply with the law? William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Dominic Saroni" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]>; "'WEDi/SNIP ID & Routing'" <[EMAIL PROTECTED]> Sent: Wednesday, 26 June, 2002 11:39 PM Subject: RE: Transactions Listserve: Unsolicited 277 in response to claim submissions Rachel, I agree this thread should be moved to X12 Insurance TG2 WG5, where the v4040 277 Front-End Acknowledgment is being discussed. A quick note: NJ HINT does require a 277 Unsolicited v3070 standard to be replied to any claim with adjudication issues. This will be re-clarified in a NJ meeting next month. Please redirect any other questions to X12 Insurance TG2 WG5 or to me directly, if applicable. Dominic Saroni Associate Rachel Foerster & Associates, Ltd. Professionals in EDI & Electronic Commerce 39432 North Avenue Beach Park, IL 60099 Phone: 312-925-4525 Fax: 847-872-6860 http:/www.rfa-edi.com -----Original Message----- From: Rachel Foerster [mailto:[EMAIL PROTECTED]] Sent: Thursday, June 27, 2002 12:08 AM To: 'WEDi/SNIP ID & Routing' Subject: RE: Transactions Listserve: Unsolicited 277 in response to claim submissions NJ's HINT law has been on their books for almost 2 years, so the requirement for providers to file claims on behalf of their patients is not new knowledge. And obviously NJ lawmakers didn't view it as nonsense. And, how did you make the leap from a provider being required to file a claim on behalf of the patient to an unsolicited 277 transaction. NJ HINT doesn't require it, nor does HIPAA. I trust you're not trying to take on the NJ legislature on their laws here, since that is most certainly out of scope. This is not an issue that WEDi SNIP Routing should be taking up. Out of scope!!!!! Rachel 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: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Wednesday, June 26, 2002 9:07 PM To: WEDi/SNIP ID & Routing Subject: Transactions Listserve: Unsolicited 277 in response to claim submissions Here's a new one on me: Cynthia Korman told us on the WEDI/SNIP Transactions Listserve of NJ's HINT law. How is the payer going to know how to get the 277U back to the provider? And what's this nonsense about providers having to file claims on behalf of the patient? What if this is the first time the provider has ever dealt with the patient's insurance company? Is this another example of lawmakers writing rules which are almost impossible to implement? Will the Healthcare CPP Registry be of any help here? See the Health Information Electronic Data Interchange Technology Act ("HINT") at http://www.state.nj.us/dobi/pn01_63.htm. Note especially: The Department also notes that the Act does not require providers to implement electronic systems for the processing of health care transactions. The Act merely states that 12 months after HINT becomes operative all health care providers shall file claims on behalf of patients unless the patient elects to personally file the claim. It should be noted, however, that the Act does provide incentives where providers file electronically. For instance, electronically filed claims must be paid in 30 days while paper claims must be paid in 40 days. Electronically filed claims must be acknowledged by payers within two days of receipt, and paper claims within 15 days of receipt. Any discussion? Yoo-hoo!! Anyone? Or is this too far off-topic from the usual run of anti-SPAM vigilantism? William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Cynthia Korman" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Wednesday, 26 June, 2002 09:27 PM Subject: Unsolicited 277 in response to claim submissions Joe, your mention of the idea of sending an unsolicited 277 whenever a claim is submitted reminds me that great minds can think alike! Here in New Jersey, where we have the HINT law, health plans will be required to reply to claim submissions with the 277, unless a provider indicates that they cannot receive and process this transaction. For these providers, the health plan is required to provide a mutually-agreeable way of acknowledging receipt on a claim-by-claim basis. The HINT rule calls for an earlier version of the 277: X12.317 Version 003070, Release 7, sub-release O... ----- Original Message ----- From: "Barton, Joe" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Wednesday, 26 June, 2002 07:49 PM Subject: RE: an inquiry for a non-existing member It may good customer relations practice to send an unsolicited 277 whenever a claim is submitted. We do not have adjudication, once we receive a claim, and valid, it is sent off for payment. An unsolicited 277 from us would let our partners know either it passed edits, and is off to be processed for payment (1-2 days) or if there was something wrong with the transaction. discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. 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