Have to agree with Rachel. Please move this discussion elsewhere where we can get more folks involved. Perhaps "transactions"?
----- Original Message ----- From: "Rachel Foerster" <[EMAIL PROTECTED]> Date: Wed, 3 Jul 2002 11:18:24 -0500 To: "'WEDi/SNIP ID & Routing'" <[EMAIL PROTECTED]> Subject: RE: The use of Supplemental IG's > Please excuse my confusion here, but I don't see how the use of companion > guides is related to the challenges of addressing and routing. Are we > getting off on a non-essential tangent to the primary goal of this group? > > 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: Tuesday, July 02, 2002 3:20 PM > To: WEDi/SNIP ID & Routing > Subject: Re: The use of Supplemental IG's > > > Just out of curiosity, I went to the CMS web site to see if there were > any Program Memos or Transmittals that had stuff about restricting > inbound delimiters Sure enough, one of the first I picked out, > Transmittal B-01-71 of NOVEMBER 8, 2001, says incoming 837 Professional > transactions must utilize delimiters from the following list: >, *, ~, > ^, |, and: - exactly the situation I was bemoaning! What if another > payer wants me to use the group, record and unit separators (hex 0x1D, > 0x1E and 0x1F) only? Arbitrary special conditions for every payer! - > precisely the problem standard transactions were meant to take care of! > > To top it off, I see where it also says Currency code (CUR02) must equal > 'USA' - I take this to mean that CMS wants all amounts in U.S. Dollars, > even if the billing provider is Canadian, for example. But this can't > possibly make any sense since the currency code must be one of the > internationally recognized codes from ISO 4217. "USA" is not among > them - "USD" is the symbol for the U.S. Dollar. So would I have to make > a special exception in my mapping for just CMS in order to use an > invalid currency code - because that's "just the way they do it." My > data wouldn't even make it past a halfway self-respecting compliance > analyzer using CMS' made-up codes. Or perhaps it was a typo? > > I have no problem with a companion guide that says what the payer is > going to use from the particular standard transaction. But to reinvent > the X12 and HIPAA IG syntax rules wholesale, as CMS is doing here, is > clearly prohibited by the HIPAA TCS rule. I wouldn't be surprised if > this kind of stuff becomes epidemic, and we're back to where we started > from: one-off payer-specific IGs. > > For the purposes of our project, let's assume by October 2004 that we'll > truly have standard IGs - and payers abiding by them! > > William J. Kammerer > Novannet, LLC. > Columbus, US-OH 43221-3859 > +1 (614) 487-0320 > > ----- Original Message ----- > From: "Bruce T LeGrand" <[EMAIL PROTECTED]> > To: "WEDi/SNIP ID & Routing" <[EMAIL PROTECTED]> > Sent: Tuesday, 02 July, 2002 01:15 PM > Subject: The use of Supplemental IG's > > > <SNIP> > But now individual EDI guidelines dictated by the payer are a thing of > the past. As an aside, I do suspect that some payers will try to use > "companion" guides in much the same way, thinking they're just renamed > implementation guides. Except now, they will find that most of the > (arbitrary) restrictions they place in these "companion" guides are > unenforceable: I've even seen these guides say what particular X12 > delimiters to use! A payer (or provider, or clearinghouse for that > matter) must take a standard transaction as long as it conforms to the > HIPAA IG: if the sender's delimiters are acceptable by the X12 > application syntax rules and the HIPAA IG, the recipient should be the > one doing the adapting. > <END> > > > Its not that I always want to be arguing against a position Mr. > Kammerrer has taken, but I seem to find reasons all of the time. > > That said, payers are required to accept transactions. They are not > required to adjudicate them, they are not required to do more that > acknowledge the file with a 997. Thereafter, a status inquiry could be > returned with a no record of this claim, and still meet the guidelines. > Supplemental IG's are designed to ensure that this does not happen as > often as it may otherwise. There are still business issues, not > addressed adequately by the consensus process of the X12N group, yet, > that require more specific information and usage. > > One payer that comes to mind immediately and is publishing a substantial > supplemental IF is CMS, or more precisely Medicare Part A. If you think > providers that file for part A claims are going to ignore this > information, or this guide, you are sorely mistaken. I have cut a sample > from a source: > > The Centers for Medicare & Medicaid Service has issued updated > guidelines for submitting Medicare Part A test claims in the ANSI X12N > 837 Institutional format, which is required under the Health Insurance > Portability and Accountability Act (HIPAA): The ANSI 837 v4010 > Institutional Implementation Guide (IG) does not provide a place to > report the start of care date for hospice outpatient claims. CMS has > developed the following guidelines for submitting Outpatient Hospice > claims via the 837 v4010 format: > > The 837 2300 loop Admission Date segment must be used to report the > start of care date for outpatient hospice claims. Submit "0001" as a > default hour and minute (HHMM) part of the admission date data element > if the information is not available. To use the CR6 (Home Health Care > Information) segment in the HIPAA 837 Institutional IG to report the > start of care date for home health claims, all required segments must be > used. CMS has developed the following guidelines for submitting Home > Health claims via the 837 v4010 format: > > The 837 2300 loop Admission Date segment must be used to report the > admission date/start of care date for home health claims. Submit "0001" > as the default valued for the hour and minute (HHMM) part of the > admission date data element if the information is not available. The > ANSI 837 v4010 Institutional Implementation Guide (IG) allows for only > one Investigational Device Exemption (IDE) per claim. Please submit only > one IDE per claim, either when submitting HIPAA test claims or, > subsequent to testing, when submitting HIPAA production claims. HIPAA > test or production claims submitted with non-numeric revenue codes will > be returned to the provider (RTP) with an appropriate error message. You > should use HCPCS codes, rather than National Drug Codes (NDCs), to bill > for drugs submitted on HIPAA inpatient test and production claims. CMS > will determine at a later time when Medicare will accept NDCs. Employer > status code, employer name and employer address is no required on claims > submitted in the ANSI 837 v4010 format. Notices of Election (NOEs) are > not established under HIPAA. Do not use the ANSI 837 v4010 transaction > for NOEs. The Subscriber Demographic Information or DMG segment includes > information on the gender and date of birth of the holder of a > supplementary insurance policy if it is not the beneficiary. Medicare > does not require this information. However, it may be required on claims > being forwarded for supplemental coverage. Medicare will forward this > information when submitted on a claim that is forwarded to a > supplementary insurer. You should continue to enter a "0001" revenue > code line which contains the sum of charges in your ANSI 837 v4010 > transaction. Discharge Hour information is required on all final > inpatient claims/encounters. For testing purposes, use "0001" for DTP03. > For HIPAA claims that require a unique physician identifier number > (UPIN) in the 2310A (Attending Physician Information) loop, use code > "24" in NM108 and enter a "dummy" 10-digit numeric employer's > identification number (EIN) in NM109. Enter the UPIN in 2310A REF02. The > Direct Data Entry (DDE) system will be updated to reflect the claim > requirements outlined in the Implementation Guide. Examples of DDE claim > entry changes include only one IDE per claim, inclusion of Discharge > Hour information, and removal of employment status code, employer name > and employer address. HIPAA test claims cannot be submitted via Direct > Data Entry. Look for more information on changes to your Part A DDE > system published in future Medicare Advisories or posted under the HIPAA > section of our Web site. The date of receipt will be translator > generated and mapped to the Medicare Part A Claim / COB flat file. > > There are additional requirements, perhaps a page or two, that were > published in the original supplement as well. This is the way you do > business with X12. It is not an absolute process. It is a negotiation > between trading partners. Any attempt to impose an absolute standard > must infringe on the internal business systems and cannot be done from > an external communication data standard. > > Besides, it takes time to make changes in X12. If something new comes > along, are you willing to wait for that lifesaving procedure while a > consensus is built on how to code it for claims filing, or would you > rather allow the provider/payer to negotiate a means of meeting the > requirement under an existing standard. > > Its not that I always want to be arguing against a position Mr. > Kammerrer has taken, but I seem to find reasons all of the time. > > That said, payers are required to accept transactions. They are not > required to adjudicate them, they are not required to do more that > acknowledge the file with a 997. Thereafter, a status inquiry could be > returned with a no record of this claim, and still meet the guidelines. > Supplemental IG's are designed to ensure that this does not happen as > often as it may otherwise. There are still business issues, not > addressed adequately by the consensus process of the X12N group, yet, > that require more specific information and usage. > > One payer that comes to mind immediately and is publishing a substantial > supplemental IF is CMS, or more precisely Medicare Part A. If you think > providers that file for part A claims are going to ignore this > information, or this guide, you are sorely mistaken. I have cut a sample > from a source: > > The Centers for Medicare & Medicaid Service has issued updated > guidelines for submitting Medicare Part A test claims in the ANSI X12N > 837 Institutional format, which is required under the Health Insurance > Portability and Accountability Act (HIPAA): The ANSI 837 v4010 > Institutional Implementation Guide (IG) does not provide a place to > report the start of care date for hospice outpatient claims. CMS has > developed the following guidelines for submitting Outpatient Hospice > claims via the 837 v4010 format: > > The 837 2300 loop Admission Date segment must be used to report the > start of care date for outpatient hospice claims. Submit "0001" as a > default hour and minute (HHMM) part of the admission date data element > if the information is not available. To use the CR6 (Home Health Care > Information) segment in the HIPAA 837 Institutional IG to report the > start of care date for home health claims, all required segments must be > used. CMS has developed the following guidelines for submitting Home > Health claims via the 837 v4010 format: > > The 837 2300 loop Admission Date segment must be used to report the > admission date/start of care date for home health claims. Submit "0001" > as the default valued for the hour and minute (HHMM) part of the > admission date data element if the information is not available. The > ANSI 837 v4010 Institutional Implementation Guide (IG) allows for only > one Investigational Device Exemption (IDE) per claim. Please submit only > one IDE per claim, either when submitting HIPAA test claims or, > subsequent to testing, when submitting HIPAA production claims. HIPAA > test or production claims submitted with non-numeric revenue codes will > be returned to the provider (RTP) with an appropriate error message. You > should use HCPCS codes, rather than National Drug Codes (NDCs), to bill > for drugs submitted on HIPAA inpatient test and production claims. CMS > will determine at a later time when Medicare will accept NDCs. Employer > status code, employer name and employer address is no required on claims > submitted in the ANSI 837 v4010 format. Notices of Election (NOEs) are > not established under HIPAA. Do not use the ANSI 837 v4010 transaction > for NOEs. The Subscriber Demographic Information or DMG segment includes > information on the gender and date of birth of the holder of a > supplementary insurance policy if it is not the beneficiary. Medicare > does not require this information. However, it may be required on claims > being forwarded for supplemental coverage. Medicare will forward this > information when submitted on a claim that is forwarded to a > supplementary insurer. You should continue to enter a "0001" revenue > code line which contains the sum of charges in your ANSI 837 v4010 > transaction. Discharge Hour information is required on all final > inpatient claims/encounters. For testing purposes, use "0001" for DTP03. > > For HIPAA claims that require a unique physician identifier number > (UPIN) in the 2310A (Attending Physician Information) loop, use code > "24" in NM108 and enter a "dummy" 10-digit numeric employer's > identification number (EIN) in NM109. Enter the UPIN in 2310A REF02. The > Direct Data Entry (DDE) system will be updated to reflect the claim > requirements outlined in the Implementation Guide. Examples of DDE claim > entry changes include only one IDE per claim, inclusion of Discharge > Hour information, and removal of employment status code, employer name > and employer address. HIPAA test claims cannot be submitted via Direct > Data Entry. Look for more information on changes to your Part A DDE > system published in future Medicare Advisories or posted under the HIPAA > section of our Web site. The date of receipt will be translator > generated and mapped to the Medicare Part A Claim / COB flat file. > > There are additional requirements, perhaps a page or two, that were > published in the original supplement as well. This is the way you do > business with X12. It is not an absolute process. It is a negotiation > between trading partners. Any attempt to impose an absolute standard > must infringe on the internal business systems and cannot be done from > an external communication data standard. > > Besides, it takes time to make changes in X12. If something new comes > along, are you willing to wait for that lifesaving procedure while a > consensus is built on how to code it for claims filing, or would you > rather allow the provider/payer to negotiate a means of meeting the > requirement under an existing standard. > > > > 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/. > Posting of advertisements or other commercial use of this listserv is > specifically prohibited. > > > 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/. > Posting of advertisements or other commercial use of this listserv is > specifically prohibited. > > -- __________________________________________________________ Sign-up for your own FREE Personalized E-mail at Mail.com http://www.mail.com/?sr=signup Save up to $160 by signing up for NetZero Platinum Internet service. http://www.netzero.net/?refcd=N2P0602NEP8 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/. Posting of advertisements or other commercial use of this listserv is specifically prohibited.
