Kepa, While I can follow and understand Stanley's (CMS') proposal, I am concerned that it too now adds another level of detailed complexity for the industry to interpret, sort out and then determine what type of entity or role a given entity may be playing.
Layering levels of detail of complexity for evaluation upon layers upon layers, in my opinion, neither simplifies administrative processes nor reduces costs. I don't have the magic solution, but I think this gets ever more complex..... 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: Kepa Zubeldia [mailto:[EMAIL PROTECTED]] Sent: Wednesday, June 26, 2002 7:46 PM To: [EMAIL PROTECTED]; Leah Hole-Curry Subject: Re: Clearinghouse Clarification Leah, First let me say that Stanley presented a proposal at the AFEHCT meeting. Not a final official HHS answer, but a proposal for comments. This is not the first time that HHS presents a proposal for comments at AFEHCT meetings, and we take them very seriously. I wish you had been there, it was a great meeting. I hope Stanley also gets all these comments in this SNIP list server. The proposal made the clear distinction between a "transaction" and "data" by saying that a Clearinghouse converts from non-standard "transactions" into standard "transactions" whereas a business associate creates a transaction out of data. For example, a billing service typically would not be a clearinghouse because they would be creating the transaction out of data they receive from the provider. A clearinghouse could (would) receive a transaction from the provider in the print image format (HCFA-1500) and supplement it with clearinghouse data such as new identifiers and other pieces necessary to produce a HIPAA transaction. In that case, the clearinghouse, having received a "claim transaction" in the form of the HCFA-1500 would be acting as a clearinghouse, in spite of the fact that they are also supplementing the transaction from external data. The distinction is that what the clearinghouse received was a non-HIPAA "claim" as we know it today. That HCFA-1500 is a self contained non-HIPAA claim. Compare that with a billing service that gets a "superbill" from the provider and produces a claim. That is not a clearinghouse because they are not receiving a "claim" from the provider. Again, this was a draft for comment. Your comments will be very much appreciated. Kepa On Tuesday 25 June 2002 07:56 am, Leah Hole-Curry wrote: > 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 > Information transmitted is confidential and may be proprietary to FOX > Systems, Inc. It is intended only for the person or entity to which it > is addressed. Anyone else is prohibited from disclosing, copying, or > disseminating the contents or attachments. If you receive this in > error, please notify sender immediately, or us at www.foxsys.com and > delete from your system. > >>> [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 simple > > definition. > > 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 the > > patient 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 > > > > > > > > > > > > > > > > > > > > > ********************************************************************** > > > > To be removed from this list, send a message to: > > > > [EMAIL PROTECTED] > > > > Please note that it may take up to 72 hours to process your > request. > > > > > > > > ====================================================== > > > > The WEDI SNIP listserv to which you are subscribed is not > moderated. > > > The > > > > 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. 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