I agree with you that once in production - compliance may or may not be a critical issue but the discussion started out around certification. Take a look at the message posted under that subject and let me know your thoughts.
Thanks -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Monday, December 02, 2002 9:30 AM To: WEDI SNIP Testing Subworkgroup List Subject: Re: Defining a health care claim within the context of the 837 implementation guide I guess there's no doubt that the 2300 loop is a "claim" - 'cause it's right there in the HIPAA IG called "Claim information." But in any event, where does it say that you're going to get into trouble if you accept a claim (or 837) which is not perfectly "compliant"? I see in the Rule where it says the Plan has to accept standard transactions. Therefore, I can imagine a provider who's sent a perfectly compliant 837 - which has been rejected - now has a leg to stand on when she complains to HHS about the big bad payer. Thus, it certainly behooves the payer to be able to accept any compliant claim. But whoever is going to complain when the payer accepts and pays claims with bad zip codes, or no service facility address (how would anyone know it was needed anyway), or phony newborn weights when it doesn't otherwise require them? Before penalties kick in, I would expect someone to have been harmed - i.e., the provider. A provider who sends an otherwise compliant claim is harmed when the payer refuses to accept it - she can't make it any more "compliant," can she? Her only other choice with an obstinate payer would be to submit paper or else she won't get paid. And it's unlikely a payer is going to complain about "non-compliant" transactions from a provider; if he chooses not to process them, and if the provider whines, he can always tell her to go check out her transaction with Claredi or whoever to satisfy herself that the transaction is slop. Is this "penalties" business more HIPAA-hysteria? William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Rachel Foerster" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Sent: Monday, 02 December, 2002 12:03 PM Subject: Defining a health care claim within the context of the 837 implementation guide Marcallee, I propose that you change the subject line for this specific message thread, since it appears the issue is not one of validation or certification, but rather, Rachel Foerster ----- Original Message ----- From: "Marcallee Jackson" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Sent: Monday, 02 December, 2002 10:52 AM Subject: RE: RE: VALIDATION or Certification My initial suggestion that, for the purpose of this message string, we define a claim as each 2300 loop was based on item 3 from Kepa's earlier message On Monday, November 25, 2002 10:15 PM Kepa Zubeldia wrote: What is a claim? Is it the entire 837 with hundreds of 2300 loops, or is it each one of the 2300 loops? From the business perspective of healthcare, it is each one of the 2300 loops. From the EDI perspective, it could well be the entire 837. It would be nice to get a clarification from HHS on this, as it could very well affect the penalties. I believe the covered entities are required to have perfect claims, but we need to know the scope of a claim. See point #4. As for the certification, both should be measured, how Many 2300 loops are good and how many ST-SE transactions are good. The number of 2300 loops per ST-SE is another important metric. Of course, I am assuming that all transactions must at least be compliant with X12 syntax or the whole ST-SE would be bad. But, will a bad ZIP code cause an entire 837 to be bad even if it only happens in one out of 10,000 claims? I say that is too drastic a position. So sounds like in terms of defining a claim - we are in agreement that each 2300 loop would equal a business transaction a/k/a claim. --- 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. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. These listservs should not be used for commercial marketing purposes or discussion of specific vendor products and services. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. 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