I have some additional questions regarding the HIPAA transaction sets and
"rules" for rejecting them.
In X12 formats, I believe the receiver of the data can reject a transaction
set via functional acknowledgment if the data does not meet correct X12
syntax.
My question comes into play with the variable levels of acceptance for the
997. Since an interchange can fail at the functional group, transaction set
and segment level, what is our responsibility for accepting a file that fails
within a single transaction set when there are multiple trans. sets in the
file?
Can we legally process the good portions of the file and reject only the bad?
What if there is a problem with a single claim within a transaction set?
**** You can reject at the ISA, GS, ST or Claim level for example. There is
no law requiring you to do one over the other. However, I have always
suggested editing at all levels because it decreases the impact on the claims
adjudication system, the providers cash flow, etc... If the provider sends 100
claims in 4 ST's and one ST has a problem, you set aside that one ST with 25
claims and process the other 75 claims. When the provider fixes the problem,
they will most likely have to retranslate those 25 claims because syntax
problems don't go away if you just retransmit the original. Example 2, If you
receive one ISA with two ST's.. one is a 997 and one is an 837 with 100
claims. If the 997 has a syntax problem, allow the translator to pull out the
997 and process the ST - SE loop that contains the claims.. don't throw out
the whole ISA - IEA.
Additionally, since the Regulation is not intended to change the way a payer
"does business", we should still be able to deny/reject claims based on
certain business rules (i.e. invalid diagnosis code, invalid procedure /
modifier code combo, invalid dates, non-numeric data in a numeric field,
etc.) correct??
** yes you can and I believe very strongly that you should do these edits in a
central place on the front-end to prevent junk from getting to the subsystem.
Finally, (for now) what are the liabilities for notifying the sender of the
data if there are problems with both the data validity and the syntax?
** you could choose to not send a 997, an edit report, etc back to the trading
partner that just sent you the transaction.. because the law doesn't require
the 997 or an edit report.. however it is your best interest as a business to
give back "electronic messages/reports" that tell the sender what went wrong
and why. If you don't do this, your help desk will be spending a lot more
time on the phone answering the simple question.. what ever happened to ....
Hope that helps
Jonathan Showalter
Omaha NE USA
402-343-3381
[EMAIL PROTECTED]
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