Chris: here's an update...ten medical specialty societies' representatives will meet in mid-August for a full day to discuss HIPAA-EDI, vendor readiness issues, and CMS response to our concerns. We've made a lot of progress in terms of self-education and awareness that a proactive approach by the membership organizations that represent the majority of America's physicians is needed.
The group is staying "close to home" right now, that is, limiting initial work to physicians' membership organizations. However, I have discussed the AOA's progress, and there is interest and openess to alliances or collaboration later on.
Keep on truckin' DCK
-----Original Message-----
From: Christopher J. Feahr, OD [mailto:[EMAIL PROTECTED]]
Sent: Friday, June 28, 2002 8:05 PM
To: [EMAIL PROTECTED]
Subject: Re: 270/271 Question(s)
Bruce,
I'm glad to see that the vision industry is not alone with this type of
headache! If there is any way payors could simplify benefit plan rules, I
would be eternally grateful. In the meantime, however, providers are
entitled to have this information delivered to them in a usable, electronic
form. Generally, this adjudication logic is already described in narrative
form somewhere in the provider's office. Returning this as free text in a
271 will be about as helpful as finding it in his own provider manual or
having it read to him over the phone. But to be *really* useful in
answering the specific question that he or the patient has, it should be in
a machine-understandable form.
One way or the other, all "provider eligibility queries" feel like "pricing
queries" to me. Either the patient or the provider wants to know what
something will cost and/or what the associated reimbursement or write-off
might be... both now and later on, as treatment progresses. As I just said
in my response to the "pre-determination" question, I believe that we are
eventually going to have to codify all of the logical elements that payors
might conceivably use in eligibility/payment formulas. That way, the payor
could return the actual parameter values that apply to Patient X with Plan
Y, and the provider system could insert those into the [relatively static]
formulas that he has pre-programmed in his system for Plan Y, thereby
enabling his system to answer whatever "pricing" question the patient or
provider was asking. For the less capable provider, you could also return
the free text description of benefits in an MSG segment.
This will require a collaborative effort among payors to describe all the
different formulas that have been dreamed up. >From that, we should be able
to develop standard terminology for the logical elements and assign a LOINC
code to each element. Presumably, this logic is already codified in each
payor's adjudication system, meaning that someone has already gone through
this process. Hopefully, this would also have a stabilizing effect on plan
structures and logic.
How does this approach strike payors? Wouldn't this provider-capability
reduce phone calls from provider offices?
Regards,
Chris
At 09:49 AM 6/28/02 -0400, you wrote:
>How am I supposed to code the following benefits in a 271? And these are
>only a sample. Should I just "give up" and put everything that doesn't
>readily code in an MSG segment? Is there any explanation of what the codes
>mean anywhere? What is everyone else doing?
>
>Participating Hospital Emergency room covered: 100% after $50 copay
>EB01 = A or B?, EB03 = 51 or 53? EB07 = 50 EB08 = 100
>
>
>Specialist Office Visit Copay: Same As Any Other Physician
>EB01 = B EB03 = 98? Professional (Physician) Visit - Office EB05 =
>Specialist Same As Any Other Physician
>
>
>and finally:
>
>Inpatient Hospital benefit: $250 deductible, then $150 Copay per day up to
>5 days per admission then 90%
>
>??? - MSG?
>
>
>
>
>
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Christopher J. Feahr, OD
http://visiondatastandard.org
[EMAIL PROTECTED]
Cell/Pager: 707-529-2268
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