This is not a clearinghouse issue to fix. What if the 300,000 claims are coming from an entity that is not a clearinghouse? What if it's 3000 files of 100 claims each with 1 problem? Very, very, very few submitters have front-end editing to ensure compliance, with HIPAA or payer specific requirements, so payers who accept direct transactions can expect to see errors in many of the transaction sets they receive.
When it comes to real life production, hard-line approaches like this simply will not work. I think your clients might need to get ready to receive an awful lot of paper. I know of a good scanning solution if you think that might help ;). Marcallee -----Original Message----- From: Julie Thompson [mailto:[EMAIL PROTECTED]] Sent: Wednesday, December 04, 2002 4:57 PM To: WEDI SNIP Testing Subworkgroup List Subject: RE: Defining a health care claim within the context of the 837 implementation guide 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. --- 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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