RE: 278 question

[Fields, Michael]

See my comments below in blue ...

-----Original Message-----
From: Connie Lagneaux [mailto:[EMAIL PROTECTED]]
Sent: Friday, June 14, 2002 11:44 AM
To: '[EMAIL PROTECTED]'
Subject: FW: 278 question


Someone must have an idea...!?!

>  -----Original Message-----
> From:         Connie Lagneaux 
> Sent: Monday, June 03, 2002 12:35 PM
> To:   '[EMAIL PROTECTED]'
> Subject:      278 question
>
> Hi,
>
> I have a couple of questions related to the following scenario:
>
> A payor is providing a web based product to their providers for the
> submission of referral/authorization requests.
>
> 1.  For the CR608 segment, does every certification type code have to be
> offered online?  I think some payors may not want to do appeals
> electronically, especially when the PWK (Paperwork) segment has not been
> implemented (as described in the 278 addenda document).  Additionally,
> some plans may not have "Extension" of ref/auth in their current business
> processes, but may instead require new requests be submitted.
>

The feedback we have gotten on this issue is that you are not required to offer code set choices that you cannot feasably process due to the way your business process works.  In some cases we are limiting code set choices on our web-based authorizations system for this reason.

> 2.  Can the screen display "Plan or Payor" terms for Service Type Codes
> (UM03) ?  This assumes that the mapping is appropriate and does not change
> the intent of the UM03 code.  For example "Consult" for UM03 3,
> "Consultation"  and "Specialist Visit" for UM03 99, "Professional
> (Physician) Visit - Office."
>

Yes, we have asked this specific question to HHS and got the following response:

 

"The critical item is that you provide at least the HIPAA codes. Additional explanatory information is optional - it can be shown, but is certainly not required. Nor can the additional information put restrictions on the codes which would be in conflict with the IG or the code set maintainer."

-Stanley Nachimson

 

So the bottom line is that you can use custom descriptions as long as you provide the actual code value as well and

your custom description does not change the intent or meaning of the code.

 

> 3.  If no field currently exists on the entry screen for Location (Health
> Care Service Location) for those services where location is not implicit
> by the identified provider,  would a resolution of the following be
> compliant:  adding service types of (for example) hospice/home and
> hospice/inpatient on the screen AND behind the scenes for the transaction
> map to UM03 42 plus UM04 appropriate information per each service type
> just mentioned.
>

 

In doing this you may be violating the DDE exception rule #2 (see below) .. I would

try to get clarification on this from HHS.  I would suggest sticking to the HIPAA UM03

codes and adding a seperate web field with values inpatient or outpatient and flag this

field as outside of the HIPAA specifications.  Similarly, in our web application, we

provide the choice at the beginning of the process of whether the authorization is for

inpatient or outpatient services .. though in our case we cannot infer the value of

UM04 as certain UM04 values other than inpatient or outpatient have implications to

our processing of the authorization.

 

DDE exception rules:

1. Collect all data elements that are required in the implementation guide, as well as those data elements that are situational and the situation is met (unless the data are already available on the health plan's system);
2. Use only the internal and external code sets designated in the implementation guide with no additions or substitutions;
3. Provide for at least the field size minimums noted in the implementation guides, but no more than the maximum sizes; and
4. Permit at least the minimum number of field repeats noted in the implementation guide, but not more than the maximum number.

Hope this helps ...

 

 

-Michael Fields

[EMAIL PROTECTED]

 

> thanks,
> Connie Lagneaux
>
>
>
>      
>