This is just my opinion, but it seems clear to me that this is in violation of the spirit (and heart and soul) of the guideline and is probably in violation of the 'letter of the guideline.' Claim notes are not meant to contain information that is available elsewhere in the transaction. I have run into several similar issues in reviewing Payer Companion Guides.
-----Original Message----- From: Kerry Zajicek [mailto:[EMAIL PROTECTED] Sent: Friday, February 28, 2003 6:36 PM To: WEDI SNIP Testing Subworkgroup List Subject: RE: Payers and Optional Fields - Another Example Looking for thoughts on a similar situation........ We've been informed of the following billing requirement, when sending a claim with more than 2 modifiers the provider must put the modifier '99' and the entire modifier list in the situational NTE Claim Note segment in L2300. Based on the IG notes for this segment (below) it seems to me that this is in violation of the guide requirements, or am I missing something? Notes: 1. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who require narrative information with claims are encouraged to codify that information within the ASC X12 environment. 2. Required when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) in the opinion of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. Have others run into a similar requirement and how was it handled? Thanks Kerry D. Zajicek EDI - Claims Epic Systems Corporation 5301 Tokay Boulevard Madison, WI 53711 [EMAIL PROTECTED] (608) 271-9000Kerry -----Original Message----- From: Kepa Zubeldia [mailto:[EMAIL PROTECTED] Sent: Friday, February 28, 2003 2:55 PM To: WEDI SNIP Testing Subworkgroup List Subject: Re: Payers and Optional Fields John, >From what I have seen, most of these situations result from a poor understanding of the IG. I would recommend that the provider tries to work with the payer to resolve it. Only if the payer is willfully and knowingly in violation of the guide requirements and does not want to work with the provider in addressing the problem, then the provider will have to complain to CMS as a last resort. For example, if the payer wants to receive all the dates with slashes in them, as in "02/28/2003" and will not accept dates any other way. That would be pretty blatant violation. But, even then, I would recommend the provider to take the dialog route first, and leave the litigation route as a last last last resort. Just my opinion, of course. It may not reflect my employer's opinion. Kepa Zubeldia Claredi On Friday 28 February 2003 10:37 am, John Craft wrote: > What would anyone suggest a provider do if they feel a payer "will not > accept something that is valid in the guide, or that they require something > the guide does not require (including situational requirements)."? My > experience tells me that most providers will 'cave' to the payer demand, > either because they just don't know enough about the standard or so they can > get paid, thereby eroding the standard. Should the provider file a complaint > to CMS stating they believe the payer is non-compliant with the data element > standards defined in the guides? What else can we do to make sure the > 'theory' of true standardization will be come 'reality' in October? > > John Craft > Partner, HCS > 334-396-0833 > > -----Original Message----- > From: Kepa Zubeldia [mailto:[EMAIL PROTECTED] > Sent: Friday, February 28, 2003 9:06 AM > To: WEDI SNIP Testing Subworkgroup List > Subject: Re: Payers and Optional Fields > > > Miriam, > > The content of the transaction is under the control of the submitter as long > > as the submitter is complying with the implementation guide. The theory is > that a payer cannot say that they will not "accept" something that is valid > in the guide, or that they "require" something the guide does not require > (including situational requirements). That is the HIPAA theory. > > The reality, at least today, is different. Will the reality change after > October 16? Maybe... But as of today, a payer that has filed for the ASCA > extension, or small health plans that did not need to file for the ASCA > extension, do not need to be compliant with HIPAA yet, so they can > superimpose their own requirements. Perhaps that will change in October. > At > least it "should" change. Or is it "must" change? :-) > > As for the Taxonomy code, if the payer says "I need the taxonomy code > because > it impacts my adjudication system" then the provider MUST send it because > that is what the implementation guides (Addenda) now require. > > Kepa Zubeldia > Claredi > > > > > On Friday 28 February 2003 07:08 am, Miriam Paramore wrote: > > This is probably the 100th time this has been asked... but bear with > > me. > > > > Can a payer mandate that a provider put a certain value in an optional > > field? Unisys has stated that it is requiring the taxonomy code in an > > optional field, and will not pay the claim unless that optional field > > is present. > > > > I think this flies in the face of all things HIPAA standard. Isn't > > that type of payer behavior expressly prohibited? Still, other payers > > felt that they could get by with such a mandate as a "business rule" > > between trading partners. Sounds like the dog is still getting > > wagged. Best Regards, > > > > Miriam J. Paramore > > President & CEO > > PCI: e-commerce for healthcare > > 9001 Shelbyville Road > > iTRC Building > > Louisville, KY 40222 > > 502-429-8555 > > www.hipaasurvival.com =========================================== > > This email contains confidential information intended only for the named > > addressee(s). Any use, distribution, copying or disclosure by any other > > person is strictly prohibited. > > > > > > > > > > > > --- > > 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. 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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. > > You are currently subscribed to wedi-testing as: [EMAIL PROTECTED] > To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] > If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org > > -- This email contains confidential information intended only for the named addressee(s). Any use, distribution, copying or disclosure by any other person is strictly prohibited. --- 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. You are currently subscribed to wedi-testing as: [EMAIL PROTECTED] To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org --- 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. You are currently subscribed to wedi-testing as: [EMAIL PROTECTED] To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org --- 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/. 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