William, et al -- There are 2 issues I'd like to weigh in on:
1) While you (via Kepa) make a valid point that payer-to-payer COB will not necessarily always mean a separate trading partner agreement, the fact is that real business payer-to-payer almost certainly does have such contracts/agreements. Remember the complex business arrangement implicit in payer-to-payer COB. It's not just a simple connect-and-send type arrangement, and is not treated as such today. And, where such agreements exist, HIPAA mandates that the standard be used. Regardless, it seems to me that any CPP solution that is to help with COB relationships would need to support TPA's. We can work towards automation in this regard within the industry, but that will take time. 2) It seems clear to me that the discussion relating to Companion Documents most certainly does belong outside of the Addressing/Routing group. There are a multitude of issues related to this topic, and it warrants its own discussion. I believe the Transactions WG is already considering how to proceed with this issue (SIG, white paper, etc.). As this discussion / work ensues, clearly the Addressing/Routing group needs to coordinate with that work, taking into account recommendations coming out of such discussions. However, this group needs to keep the focus narrow enough to accomplish its objectives. Issues like the Companion Documents can easily bog your group down, since they have their own multitude of complexities and rabbit trails. Larry -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Friday, July 05, 2002 9:08 PM To: 'WEDi/SNIP ID & Routing' Subject: CPP and COB, was The use of Supplemental IG's The text from the preamble reads the same way as the 837 IG; I see absolutely no requirement for a "prior trading partner agreement," which would imply paper and human intervention. Anyway, Kepa Zubeldia seems to have already covered this in Myth #233: COB claims, on HIPAAlive (16 Nov 2001), lifted here without any permission whatsoever: I think there is an HHS FAQ response from 11/2/2001 that is being misunderstood. Read the response very carefully: <FAQ Question> As a health plan we currently only conduct coordination of benefits (COB) with Medicare. Does the transaction and code set regulation require health plans to conduct COB with all health plans and health care providers even though they may not currently conduct COB with those entities? <FAQ Answer> No. It is the health plan's decision as to whether they coordinate benefits electronically with another health plan or a health care provider. If a health plan decides to coordinate benefits electronically with another health plan or a health care provider, they must use the standard transaction for COB. <FAQ End> It does NOT say that the plan decides whether to accept a COB claim or not. The plan MUST accept a claim that contains COB information, just as they must accept any other 837 claim. Then, once the plan has accepted a claim with COB information, the plan is not required to actually coordinate the benefits with another plan, unless they have agreed to do so. If the plan does not want to coordinate benefits, that is their choice. But, if they make that choice, they would have to pay the claim as primary. Probably not a good business practice. :-) The reason behind this is that an 837 is a claim. With or without COB information in it, it is still a claim. The plan does not need to support the COB business functionality, but they must accept the claim and adjudicate it. And, if they desire to coordinate benefits, they cannot ask for a paper version (photocopy of original EOB/RA) of the COB information that was already present in the electronic claim. I hope this helps clear up the confusion in this area. Actually, it seems Kepa has long ago solved the problem for us, and it appears there's no need for trading partner agreements (between payers) if I've read him correctly. That's all I want to know. If so, we don't have to do anything at all within the CPP to support (i.e., "announce") COB capability: it's automatic and implicit. One problem down, 2654 left to go. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Rachel Foerster" <[EMAIL PROTECTED]> To: "'WEDi/SNIP ID & Routing'" <[EMAIL PROTECTED]> Sent: Friday, 05 July, 2002 02:14 PM Subject: RE: The use of Supplemental IG's While the 837 IG may not require a prior trading partner agreement for the payer-to-payer COB model, the final transaction rule on page 50336 of the preamble certainly does. Response: Coordination of Benefits can be accomplished in two ways, either between health plans and other payers (for example, an auto insurance company), or from a health care provider to a health plan or other payer. The choice of model is up to the health plan. Under this rule health plans are only required to accept COB transactions from other entities, including those that are not covered entities, with which they have trading partner agreements to conduct COB. Once such an agreement is in place, a health plan may not refuse to accept and process a COB transaction on the basis that it is a standard transaction." 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 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.
