David,
"If an entity requests a health plan to conduct a transaction as a
standard transaction, the health plan must do so." {162.925 (a) (1)}
"A health plan may not delay or reject a transaction, or attempt
to adversely affect the other entity or the transaction, because the
transaction is a standard transaction." {162.925 (a) (2)}
"A covered entity must not enter into a trading partner agreement
that would do any of the following:
"Change the definition, data condition, or use of a data element
or segment in a standard." {162.915 (a)}
"Change the meaning or intent of the standard's implementation
specification(s)" {162.915 (d)}
Does the above clarify the allowable provider-payer relationship in
response to the situation you've described? Feel free to respond on-
or off-list should you desire.
Dave Feinberg
Rensis Corporation [A Consulting Company]
206-617-1717
[EMAIL PROTECTED]
----- Original Message -----
From: <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Friday, July 20, 2001 8:27 AM
Subject: Policy on Which Guide to Use
We are aware of a situation reported to us by a customer provider
regarding which IG to use for reporting hospital services. The
provider is
negotiating a TPA with a managed care payer for the exchange of HIPAA
transactions. The payer is insisting the provider submit ALL hospital
services using the 837 Professional transaction. We thought
professional
services would be on the 837 Professional transaction and hospital
services
would be on the 837 Institutional transaction. The 837P IG says to use
the
837P for professional claims and encounters and the 837I IG says to
use the
837I for institutional claims and encounters. Would the payer be in
violation of the HIPAA guides if they insist on reporting all hospital
services on the 837P? If the payer accepts claims for Institutional
claims
and encounters, doesn't HIPAA direct them to use the appropriate
transaction? Each respective IG was constructed to meet the needs of
those
business requirements. How would one reconcile the edit "collisions"
arising from attempting to submit Institutional claim data on an 837P
transaction or vice versa? As claims generation must be supported by
appropriate provider workflow, policies, and procedures, it would seem
that
the impact on providers' operations of allowing payers to require
usage of
a transaction without regard to the setting it was intended to support
would be a violation of the underlying administrative simplification
objectives that HIPAA demands.
If this is allowed:
We can no longer assume that, just because we send a particular
implementation of a claim, we will receive the complementary
implementation of the resulting remittance (e.g., a professional
claim
typically is paid with a remittance supplying line item payment
details).
We can no longer assume that, just because the primary payer is
billed
on a particular implementation of a claim, the same implementation
can
be used for COB billing of subsequent payers or that the EOB(s)
accompanying COB claims will match the claim implementation.
We believe this is a policy issue. If we look at the regulations that
were
issued, the implementation guides were adopted by setting. It is
specifically stated at S160.1102 Standards for health care claims or
equivalent encounter information, under paragraph (d) Institutional
Health
Care Claims, the ASC X12N 837 - Health Care Claim: Institutional,
Volumes 1
and 2, Version 4010, May 2000, Washington Publishing Company,
004010X096.
It also states in the regulations at S162.915 Trading partner
agreements,
that a covered entity must not enter into a trading partner agreement
that
would do any of the following: (d) change the meaning or intent of the
standard's implementation specification(s) - the implementation guide
is
the standard's implementation specification.
We believe the payer is requiring a non-compliant implementation.
In the meantime, we recommend the following position on the issue.
Application support of the data content for the HIPAA-required
transactions
and code sets standards is limited to only the intended settings
currently
addressed by the subject applications, and only to the degree relevant
to
the intended customer business functions supported. Support of those
HIPAA-required transaction implementation guides with
"setting-specific"
considerations will be dictated by the customer's primary setting,
except
where long-established past practices indicate otherwise. Support of
complementary transactions will presume setting consistency is
maintained.
Under this "policy statement", if care was rendered in a hospital, the
institutional implementation will be supported, except for
professional
fees, which will use the professional implementation. An eligibility
query
associated with institutional care will lead to benefits information
for
institutional care, will lead to an institutional claim, and will lead
to
an institutional claim payment and COB based on an institutional
claim/EOB
being exchanged with any subsequent payer.
David Macaleer
Siemens Medical Solutions Health Services
610.219.6305
[EMAIL PROTECTED]
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