-----Original Message-----
From: David Kibbe [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, June 26, 2002 9:01 AM
To: '[EMAIL PROTECTED]'
Subject: RE: Clearinghouse Clarification
Don: greetings. I see you're still up to your elbows in all this. I've been working part-time for the AAFP since May, and would like to talk with you sometime about the issue of clearinghouse or health data networks and physician office compliance with HIPAA TCS. I'm hearing so many conflicting reports about what the pm vendors and CHs are doing or not doing. Any time we might chat on Friday? DCK
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Tuesday, June 25, 2002 6:02 PM
To: [EMAIL PROTECTED]
Subject: Re: Clearinghouse Clarification
So,
What you're saying (or what Stanley is saying) is if an organization uses
more than one inbound proprietary record to create a single outbound
standard transaction it's a "Business Associate", but if they use only one
inbound proprietary record to create a single outbound standard transaction
they're a clearinghouse. This seems like a very strange distinction to me.
I thought if we transformed nonstandard format or nonstandard data into
standard format and standard data we were a clearinghouse. There was never
any mention of one or more records.Put another way. If an organization offers a translations service for
'provider numbers' translating from a hospitals assigned number to the
health plan's assigned number or to the National Provider ID when that is
available and that conversion is done from a stored file or table that was
provided by the submitting provider to the clearinghouse/business
associate, but all the in-bound actual claim information comes on another
file. In this case, when the standard formated transaction with standard
content is formed from the stored provider numbers and the inbound
proprietary claim file, this process would make that organization a
"Business Associate" not a "Clearinghouse" - right? Well, this really
doesn't make sense to me.I do understand that a clearinghouse can also be a "business associate" to
their customers. When they might perform value added services, such as the
one I just describe. However, this organization is still performing the
other function, i.e., translating from nonstandard format to standard
format and from nonstandard content to standard content. This is the
definition of a clearinghouse according to the Transaction Regulations.
And, according to the HIPAA Legislation, it says "the term 'health care
clearinghouse' means a public or private entity that processes or
facilitates the processing of nonstandard data elements of health
information into standard data elements." This says nothing about how many
records or files the data comes from, only that it is transformed.So, given the definitions of a clearinghouse in the regulation and in the
legislation, I don't see how one record or many records is a distinguishing
factor. I can see where an organization would be considered both a
clearinghouse and a business associate, but I don't see how performing a
business associate functions changes an organization's role as a
clearinghouse. An organiation is either transforming data and/or formats
from nonstandard to standard (or vise versa), or your not.Don
[EMAIL PROTECTED] on 06/25/2002 04:15:22 PM
Please respond to <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
cc: [EMAIL PROTECTED]
Subject: Re: Clearinghouse Clarification
Well,
My notes from the AFEHCT meeting are just as Kepa described.I got the impression that being a "complete record" versus "collecting
bits" to create a complete record is the key to the distinction. In
"collecting" you're acting on behalf of .... sort of like business
functions being outsourced ... so you're a Business Assoc not a
Clearinghouse.But if you are transforming a complete electronic record from one format to
another electronic format you have qualified as a clearinghouse.Marsha
Verizon Information Technologies Inc.
Managed Care Division
Phoenix, AZ
HOME OF THE WORLD CHAMPION ARIZONA DIAMONDBACKS
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om To:
<[EMAIL PROTECTED]>
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06/25/2002 08:34 Subject: Re: Clearinghouse
Clarification
AM
Please respond to
transactions
Kepa,
I must agree with Leah, this clarification regarding parts of a transaction
is very confusing to me. In fact, for me it only raises more questions. I
believe it will be very hard to distinguish between a proprietary record
being converted to a standards transaction and a collection of proprietary
records being converted to a standard transaction. How is this distinction
different? It seems that aggregating data from several files would be more
complicated, but still achieving the same end, i.e., translating a
proprietary format to a standard format. I think Stanley needs to explain
why aggregating data from proprietary formats is different from just
translating from a single proprietary format.Don
"Leah Hole-Curry" <[EMAIL PROTECTED]> on 06/25/2002 09:56:30 AM
Please respond to <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
cc:
Subject: Clearinghouse Clarification
Kepa,
Thanks for this update, I think many of us will be anxious to see an FAQ
or other form of clarification on this.However, the part of your message dealing with only receiving parts of a
transaction appears to be in direct conflict with the definition as
currently written and some of the entity examples listed such as billing
services or repricing companies. The key function of a clearinghouse is
"processes or facilitates the processing of health information (not a
transaction) received from another entity in a nonstandard format or
containing nonstandard data content (which could be missing data
elements) into standard data elements (again not a full transaction) OR
a standard transaction.Regards,
Leah Hole-Curry
FOX Systems, Inc.
602.708.1045
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>>> [EMAIL PROTECTED] 06/25/02 06:37 AM >>>
Colleen,Last week during the AFEHCT meeting, Stanley Nachimson of CMS clarified
that a
clearinghouse is one that converts an electronic HIPAA transaction from
a non
standard format into a standard format, or vice versa. Brilliant simpledefinition.
Converting from a paper transaction into electronic is not a
clearinghouse.
Transferring electronic transactions from one point to another without
converting formats is not a clearinghouse. Scanning a paper claim and
converting it into electronic is not a clearinghouse. Receiving
standard
claims on behalf of a payer is not a clearinghouse. Receiving standard
claims on behalf of a payer and converting them to non-standard for
delivery
to that payer is a clearinghouse.Equally interesting, receiving parts of a transaction and constructing a
transaction from the parts is not a clearinghouse. A clearinghouse must
receive and transmit a self-contained electronic transaction (e.g.,
claim)
instead of parts of it. For example, an entity that has on file the
provider
information, the subscriber information, and gets from the providers thepatient and service information from which it builds the claims in
standard
format is not a clearinghouse. Even if the patient and service
information
comes in a proprietary electronic format. The clearinghouse must
receive an
entire electronic transaction in proprietary format and produce an
entire
transaction in HIPAA standard format. Or vice versa.So, a lot of entities that thought they were clearinghouses, would fall
outside of this definition. Stanley said that there will be a
clarification
from HHS soon on this topic.I applaud HHS for dissipating this foggy topic.
Kepa
On Monday 24 June 2002 12:18 pm, Grimes, Colleen wrote:
> I think we need to be careful when we are interpreting other
organizational
> structures and I respectfully have to disagree with you. In my
> orgnaization we have contracts where the clearinghouse adjudicates and
pays
> the claim. Some payers do not adjudicate their own claims and have
> clearinghouses on their front end. In my opnion this company could be
> defined as a clearinghouse and we have to be careful when we take
positions
> regarding stucture. If this company is scanning UB92's and HCFA
1500's to
> an electronic format they are translating a paper claim into an
electronic
> format. Since the UB's and the HCFA 1500's do not as yet align with
the
> 837, it all depends what they do whit the data after it is converted.
As I
> said in my answer, it is wise to verify structure with both inside and
> external legal counsel before decideing.
>
> > -----Original Message-----
> > From: Rachel Foerster [SMTP:[EMAIL PROTECTED]]
> > Sent: Monday, June 24, 2002 1:51 PM
> > To: [EMAIL PROTECTED]
> > Subject: RE: A Clearinghouse By Any Other Name ...
> >
> > Colleen,
> >
> > I respectfully disagree with your conclusion that they are solely
> > performing
> > a clearinghouse function. I don't believe that clearinghouses
actually
> > adjudicate and pay a claim. Rather, this is usually a function that
is
> > performed by the payer. If the payer then hires another company to
perform
> > that function for them, that outside company is a business
associate. A
> > clearinghouse under HIPAA is defined as any entity that translates
> > non-standard data/format into the standard or vice versus. This
company is
> > scanning paper claims into a document imaging system and then keying
the
> > data into an adjudication system. This company's existence and role
is
> > totally transparent to the provider/payee. Thus, this company isn't
> > translating non-standard data/format into standard, but is actually
> > adjudicating the claim, and making payment based on the results of
that
> > adjudication.
> >
> > This is the rationale I used when concluding that the company is a
> > business
> > associate, but not necessarily a clearinghouse. I agree that a
> > clearinghouse
> > can play both the role of a CH and a business associate, but I don't
think
> > this company is doing so in this instance. Thus, my recommendation
to seek
> > their own legal counsel opinion. If their legal counsel concludes
they are
> > in effect a clearinghouse then there are much broader implications
for
> > them
> > as a covered entity that if they are only a business associate of a
> > covered
> > entity.
> >
> > 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: Grimes, Colleen [mailto:[EMAIL PROTECTED]]
> > Sent: Monday, June 24, 2002 11:30 AM
> > To: '[EMAIL PROTECTED]'
> > Subject: RE: A Clearinghouse By Any Other Name ...
> >
> >
> > You should always check with you legal department, but what you are
> > describing sounds like a clearinghouse function. A clearinghouse
can be a
> > buisness associate and a trading partner.
> >
> > Thanks,
> >
> > Colleen
> >
> > > -----Original Message-----
> > > From: Rachel Foerster [SMTP:[EMAIL PROTECTED]]
> > > Sent: Monday, June 24, 2002 11:44 AM
> > > To: [EMAIL PROTECTED]
> > > Subject: RE: A Clearinghouse By Any Other Name ...
> > >
> > > My opinion is that you are a business associate of the health
plan,
> > which
> > > has outsourced this function to you to perform on their behalf.
Best
> > > course
> > > of action is for you to confirm this with your company's legal
counsel
> > AND
> > > the legal counsel of the health plan for which you perform these
> > services.
> > >
> > > 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: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
> > > Sent: Monday, June 24, 2002 9:45 AM
> > > To: [EMAIL PROTECTED]
> > > Subject: A Clearinghouse By Any Other Name ...
> > >
> > >
> > >
> > >
> > > Would anyone here have an opinion of "what type of entity", from
a
> > >
> > > HIPAA Transaction Rule perspective, the following operation could
be
> > >
> > > categorized?
> > >
> > >
> > >
> > > I have an operation that receives; on behalf of a HEALTH PLAN,
paper
> > > claims
> > >
> > > from the PLAN's health care PROVIDERS (doctors, hospitals, etc.).
> > >
> > >
> > >
> > > We then take the paper claims; scan them into an imaging system,
key the
> > >
> > > claims into our own claims processing software system (off the
scanned
> > > image
> > >
> > > of the paper claim), adjudicate the claim, cut the paper check and
EOB
> > >
> > > and/or ERA and mail.
> > >
> > >
> > >
> > > The submitting providers; and the payee's on the backend have no
> > knowledge
> > >
> > > of us. The checks bear the logo/address/signature of our health
plan
> > >
> > > clients.
> > >
> > >
> > >
> > > And the address where the paper claims are mailed have the name of
our
> > >
> > > health plan clients; with a PO Box that we set up; and from which
we
> > > collect
> > >
> > > the inbound mail.
> > >
> > >
> > >
> > > Question: does this make us a "CLEARINGHOUSE"? [I had, naively
perhaps,
> > >
> > > assumed that a "HIPAA defined clearinghouse" was one that
reformatted
> > data
> > >
> > > from a non-HIPAA standard format to a HIPAA standard format or
> > vice-versa;
> > >
> > > and I had assumed that the media on both sides of this are
electronic -
> > > but,
> > >
> > > when I look at the definition below; perhaps the rule applies to
"paper"
> > > as
> > >
> > > a 'non-HIPAA standard format' as well.].
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > > Definition below for convenience - from the WEDI/SNIP Glossary
> > >
> > >
> > >
> > > Health Care Clearinghouse: Under HIPAA, this is an entity that
processes
> > > or
> > >
> > > facilitates the processing of information received from another
entity
> > in
> > > a
> > >
> > > nonstandard format or containing nonstandard data content into
standard
> > > data
> > >
> > > elements or a standard transaction, or that receives a standard
> > > transaction
> > >
> > > from another entity and processes or facilitates the processing of
that
> > >
> > > information into nonstandard format or nonstandard data content
for a
> > >
> > > receiving entity. Also see Part II, 45 CFR 160.103.
> > >
> > >
> > >
> > > Henry A Perretta
> > >
> > > HAPCO International, LLC
> > >
> > > 6302 Dunman Way
> > >
> > > Alexandria,VA, 22315
> > >
> > >
> > >
> > >
> > >
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