Isn't it the job of clearinghouses to fix these issues?
A compliant transaction will use dummy or default values in order to achieve
compliance. Yes, this is the plan for numberous BCBS across the U.S.,
including several of our clients.
Julie A. Thompson
Vice President, Concio
From: "Marcallee Jackson" <[EMAIL PROTECTED]>
Reply-To: "WEDI SNIP Testing Subworkgroup List"
<[EMAIL PROTECTED]>
To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]>
Subject: RE: Defining a health care claim within the context of the 837
implementation guide
Date: Wed, 4 Dec 2002 16:46:17 -0800
Yeah well there're the FAQ's and then there's real life. You're going
to have a hard time convincing many of us that Medicare intermediaries
will be rejecting a batch (transaction set) of 300,000 claims
(transactions) because claim # 299,996 is missing a zip code. Are you
seeing this in real life implementations and if so, can you share the
names of the carriers?
-----Original Message-----
From: Julie Thompson [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, December 04, 2002 9:32 AM
To: WEDI SNIP Testing Subworkgroup List
Subject: RE: Defining a health care claim within the context of the 837
implementation guide
HHS is the group to answer the question of whether to accept a non HIPAA
compliant transactions in production (X12 alone is NOT compliant).
I have spoken with Stanley Nachimson and non compliant production
transactions are subject to fine for both the transmitting and the
receiving
partners.
There was an HHS FAQ I am unable to find the FAQ stating the above, but
here
are some other helpful related HHS FAQs.
To submit a questions for publication go to:
http://aspe.hhs.gov/admnsimp/bannertx.htm
HERE ARE SOME VERY HELPFUIL HHS FAQs:
HHS FAQ: Question
How would someone file a complaint against a covered entity?
Answer
CMS will develop a web-based complaint management process, and will
provide information on this process as part of our HIPAA outreach
activities.
Question
What will the enforcement process look like?
Answer
The enforcement process for HIPAA transactions and code sets (and for
security and standard identifiers when those are adopted) will be
primarily
complaint-driven. Upon receipt of a complaint, CMS would notify the
provider
of the complaint, and the provider would have the opportunity to
demonstrate
compliance, or to submit a corrective action plan. If the provider does
neither, CMS will have the discretion to impose penalties.
Question
Who will enforce the HIPAA standards?
Answer
The Department of Health and Human Services (HHS)has determined that
CMS
will have responsibility for enforcing the transactions and code set
standards, as well as security and identifiers standards when those are
published. CMS will also continue to enforce the insurance portability
requirements under Title I of HIPAA. The Office for Civil Rights in HHS
will
enforce the privacy standards.
HHS FAQ: Who is required to use the standards?
All private sector health plans (including managed care organizations
and
ERISA plans, but exlcuding certain small self administered health plans)
and
government health plans (including Medicare, State Medicaid programs,
the
Military Health System for active duty and civilian personnel, the
Veterans
Health Administration, and Indian Health Service programs), all health
care
clearinghouses, and all health care providers that choose to submit or
receive these transactions electronically are required to use these
standards. These "covered entities" must use the standards when
conducting
any of the defined transactions covered under the HIPAA.
A health care clearinghouse may accept nonstandard transactions for the
sole
purpose of translating them into standard transactions for sending
customers
and may accept standard transactions and translate them into nonstandard
transactions for receiving customers.
From: "Marcallee Jackson" <[EMAIL PROTECTED]>
Reply-To: "WEDI SNIP Testing Subworkgroup List"
<[EMAIL PROTECTED]>
To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]>
Subject: RE: Defining a health care claim within the context of the 837
implementation guide
Date: Mon, 2 Dec 2002 09:50:01 -0800
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.
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- RE: Defining a health care claim within the context of the ... Julie Thompson
- RE: Defining a health care claim within the context of... Julie Thompson
- RE: Defining a health care claim within the context of... Julie Thompson
