Hi Chris,
In addition to the other responses you've received on your questions,
I've <<embedded>> some thoughts within your original message below.
I'm also looking forward to spending some time with you to discuss
vision claims and attachments at the upcoming X12 Trimester Meeting in
Miami. Please come and introduce yourself -- I'm easy to identify
:-).
Dave Feinberg
Member, HL7 Attachments SIG
Co-Chair, HIPAA Implementation Work Group
Insurance Subcommittee (X12N)
Accredited Standards Committee X12
Voting Member, HL7 and X12
Rensis Corporation [A Consulting Company]
206-617-1717
[EMAIL PROTECTED]
----- Original Message -----
From: "Christopher J. Feahr, OD" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>; <[EMAIL PROTECTED]>
Sent: Monday, August 20, 2001 1:35 PM
Subject: Is this statement correct? [RE: Vision claim]
Dear Group,
I'm beginning a conversation with a large commercial vision payor and
I was planning to make the following statement to them. I would like
to know if it is factually correct, as written. If I'm wrong or even
"slightly off base" regarding any part of it, I would appreciate your
comments.
<<Before I get to specifics, one of the fundamental underpinnings
for distinguishing between what is a claim and what is an attachment
is a global analysis of what information is used all the time -- or at
least the vast majority of the time -- to process *all* claims or
encounters. It is this healthcare industry-wide perspective that
allows the joint HL7-X12N attachments team to define a list of broad
categories for attachments; e.g., Ambulance, Emergency Department,
Rehabilitative Services, Laboratory Results, Medications, Clinical
Notes, Home Health, Durable Medical Equipment, and many many others.
Based on the several e-mail threads regarding vision services over the
past many months, I strongly suspect that Vision Services represents
another such category.>>
<<Another key principal of attachments is that they are sent only
when required: either along with a particular claim [or other
transaction] type because the provider already knows that the
additional information will be needed, or in response to an electronic
request for additional information.>>
<<Now on to the specifics.>>
"If [VISION PAYOR] requires "non-traditional-claim" information (e.g.,
specific details about the frame, lenses, coatings, spectacle-Rx,
etc., commonly included in the doctor's "purchase order") to
process/pay a claim, then the totality of that information plus the
837-information would constitute "The Claim".
<<From the perspective of attachments, I would suggest that what
is needed might be better stated as "a claim plus additional
information to support a vision claim".>>
Since a HIPAA-standard does not exist for the information normally
found on a lab purchase order, it will not be legal after 10-16-02 for
[VISION PAYOR] to receive that information electronically.
<<Afraid I do not quite concur. Under HIPAA, a provider will not
be allowed to send additional information to support a claim using a
*HIPAA standard transaction*. HIPAA standard transactions represent a
floor for the industry, not a ceiling. If the vision industry can
establish an electronic standard for the information found in a lab
purchase order, that may always be electronically sent in addition to
the HIPAA standard claim transaction. In fact, if the vision industry
can establish such an electronic standard using the same technology
(i.e., HL7 ORU message with LOINC coding) as used for other
forthcoming HIPAA attachments, then turning the vision industry
standard into a HIPAA standard could be relatively straightforward.>>
Information necessary for routine claim adjudication that cannot be
placed into a standard "837 claim" or into one of the standard "claim
attachments" (proposed by HL7 and the Claim Attachment Committee) will
have to be sent to the vision plan or its exclusive business agent,
via paper.
<<Again, I do not completely concur. Of course, a provider may
always elect to use paper to convey additional information. However,
again, see my comments above about the HIPAA standard transactions
representing a floor for the industry, not a ceiling.>>
A second alternative would be for [VISION PAYOR] to adjudicate claims
without this information."
<<Sure, if they really want to :-)>>
Thanks very much for your feedback.
-Chris
<<You're welcome. Hope the above helps. Further comments from
others also welcomed.>>
Christopher J. Feahr, OD Vision Data Standards Council
Executive Director http://visiondatastandard.org
Cell/Pager: 707-529-2268 [EMAIL PROTECTED]
<<DAF>>
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