This email is broken into two parts: 1. DDE and Clearinghouses 2. Billing Services as Clearinghouses
DDE and Clearinghouses For a clearinghouse, the issue of whether or not DDE is a provider only exception only applies to the exchange of transactions between a clearinghouse and a payer for whom it is not a business associate. Commonly called non-participating or non-par payers, these payers enter into trading partner agreements with the clearinghouse but not service agreements. Medicare is a common non-par payer. If DDE is an exception only for providers, then a clearinghouse may have to exchange only the standard with non-par payers. Because they have not been asked to perform a function on behalf of these payers, they are not a business associate and may not exchange non-standard transactions. But if the payer is participating anything goes. So long as it gets a transaction to a compliant standard in between the covered entity sending it and the one on the receiving end, the clearinghouse house may exchange non-compliant transactions with its participating network members as much as they would like. The clearinghouse may use the DDE system of the payer and any other format with standard or non-standard content, as long as it is a business associate of the payer. 162.923 Requirements for covered entities. . . . (c) Use of a business associate. A covered entity may use a business associate, including a health care clearinghouse, to conduct a transaction covered by this part. If a covered entity chooses to use a business associate to conduct all or part of a transaction on behalf of the covered entity, the covered entity must require the business associate to do the following: (1) Comply with all applicable requirements of this part. (2) Require any agent or subcontractor to comply with all applicable requirements of this part. � 162.930 Additional rules for health care clearinghouses. When acting as a business associate for another covered entity, a health care clearinghouse may perform the following functions: (a) Receive a standard transaction on behalf of the covered entity and translate it into a nonstandard transaction (for example, nonstandard format and/or nonstandard data content) for transmission to the covered entity. (b) Receive a nonstandard transaction (for example, nonstandard format and/or nonstandard data content) from the covered entity and translate it into a standard transaction for transmission on behalf of the covered entity. Billing Services as Clearinghouses I'm not certain a billing service is a clearinghouse when it takes paper - superbills/charge slips, enrollment forms, surgery authorization sheets, eligibility information, referrals, EOB's, etc. and enters data from these documents into an IS system in order to manage the overall AR of a provider, one aspect of which is to produce a claim. I don't think it serves HIPAA to find that the mere fact that the paper is eventually used to produce a standard should mean the entity producing the standard claim is a clearinghouse. Think about it; is a woman working with 2 employees in her basement; taking in paper, doing data entry, managing AR and as part of that sending out an 837 claim on her nifty new HIPAA compliant system, a clearinghouse? She's a clearinghouse because she uses a system that supports standards? She's in violation of HIPAA is she uses Medicare's DDE? I think the authors of the rule may have seen a distinction. The comment and response below, though not directly addressing paper to EDI translation, does show that the authors saw a difference between a billing service - an entity that is an extension of a physician's office- and an entity that is a clearinghouse: Page 50319 Comments and Responses Concerning the Definitions 2. Health Care Clearinghouse Comment: Several commenters requested that the definition of a health care clearinghouse be reworded. Of particular concern was the reference to other entities, such as billing services, repricing companies, etc. Commenters stated the definition would preclude these other entities from using a health care clearinghouse for format translation and data conversion. Several commenters stated health care clearinghouses play roles other than data and format conversion as described in the proposed rule. Response: If an entity does not perform the functions of format translation and data conversion, it is not considered a health care clearinghouse under our definition. Billing services, for example, are often extensions of a health care provider�s office, primarily performing data entry of health care claims and reconciling the payments received from a health plan. Health care providers may use health care clearinghouses for format translation and other services a health care clearinghouse provides. We agree the definition should be reworded and have revised the definition in � 160.103. Unfortunately the response didn't address the billing service actually "billing" the claim in between doing data entry and reconciling payments but since this is the PRIMARY purpose for a "billing" service, you'd have to believe that the authors knew there would be that interim step between the two. In May of 2000, WEDI-SNIP asked HHS specifically whether or not a billing service taking in paper and exchanging standards was a billing service. I don't think we've received a response yet. But I hope as an industry we can use the reasonableness factor on this. Marcallee Jackson Independent Consultant Long Beach, CA 562-438-6613 -----Original Message----- From: rachelmcass [mailto:[EMAIL PROTECTED]] Sent: Saturday, December 21, 2002 11:13 AM To: WEDI SNIP Transactions Workgroup List Subject: RE: Use of Direct Data Entry William - that is a very helpful assessment, and offers me some guidance on how to proceed with this. What I see from this is that even if we can get by not technically being a CE right now, it will happen, and to stay in business, we have to get involved with the transaction standards. Upon closer examination of 162.923, (now brought to my attention), it does indeed appear that the DDE exception is only for providers; the rule doesn't mention clearinghouses one way or another on this point. I suppose I could try to argue that this lack of specifically mentioning clearinghouses in that particular statement leaves room for a different interpretation, but I'm not sure that would put our company in a competitive or beneficial position at the end of the day. Besides, if we gain the ability to send 837's, is there any reason we would want to continue entering DDE? Seems to me that since the company has already examined its software options, and that this will be the kind of service our clients are looking for, the thing to do here is to proceed with the 837, eliminate DDE as part of our routine, and proceed with other transactions as our software vendor makes them available to us. As we are only required to conduct those transactions we have contracted, I think this is a practical approach. 162.925 only specifically mentions health plans as being required to conduct a standard transaction when requested to do so, I can't find anywhere else that states something similar for clearinghouses. I think that the fact is that *when* we conduct an electronic transaction, it must be in standard format, but nothing says we have to conduct all standard transactions. We are contracted by providers, not health plans. For instance, in our role, we would never exchange a 820 or 834 on behalf of providers; those simply are not transactions that occur between our clients (nursing homes) and the health plans (Medicare and Medicaid), so the possibility does not even exist that we would be asked to conduct these transactions; why, then, would we decide to have this ability? We must only "comply with all applicable requirements of this part." Rachel F is right in that the laws are not always as precise as we would like them to be, nor do they cover every contingency. As for us, we have to continue progressing somehow, so we'll do that, and keep looking for answers to act upon by the time we're ready to make the next step. At least that way, we're moving forward. I'll also mention that I'm not one of those with an information technology background, so I appreciate all the input and helping me "muddle though." -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Saturday, December 21, 2002 11:51 AM To: WEDI SNIP Transactions Workgroup List Subject: Re: Use of Direct Data Entry Rachel M: A "mere" Business Associate of a provider (in this case, a nursing home) generally can do anything with respect to transactions that the provider could have done himself. The provider could have given the claim information on paper to any of its employees, who could then have used the payer's DDE system to submit the transaction to the payer. So a BA proxy for the provider can do the same (i.e., key enter into a DDE screen). You become a CH only when you take paper (or anything else - e.g., flat files or XML) and convert it to standard format (i.e., when and if you start sending 837s). Right now, you are not converting to standard format when you key-enter into a DDE screen for the provider. Although, if you really, really read into the definition of a CH in � 160.103, combined with the DDE exception's requirement that the screen only contain standard data elements, you could make a case that even DDE key-entry is a CH function. But a CH can't use the payer's DDE system - it's an exception only for the provider!! Go figure! I would assume that as a billing service - even if you were a clearinghouse - that you have no direct contact with patients; so to whom would you give the Notice of Privacy Practices?!! And if you're not a clearinghouse - i.e., not a covered entity - then the NPP issue is certainly moot. Assuming you are simply a Business Associate, you are beholden only to the provider (the nursing homes who contracted with you) based on the BA agreement; you are not a HIPAA covered entity and have no HIPAA "liability" yourself - "the actions of business associates relating to PHI are considered to be the actions of the covered entity that engaged them." - see "HIPAA's Impact on Business Associate Relationships," at http://www.hipaadvisory.com/action/LegalQA/archives.htm. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 --- The WEDI SNIP listserv to which you are subscribed is not moderated. 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