Robert, I agree with your perspective and that this is one of the issues that standardizing both format and content HIPAA is attempting to solve.
Rachel -----Original Message----- From: Robert Barclay [mailto:[EMAIL PROTECTED]] Sent: Tuesday, October 16, 2001 9:54 AM To: [EMAIL PROTECTED] Subject: RE: Code Editing I, too, have concerns about rejecting entire transactions but I do not see it as an unresolvable problem. First of all, today's EDI rejections do not equate to tomorrow's HIPAA "non-compliance" rejections. A 10% rejection rate today will not mean most HIPAA transaction will be rejected in the future. Many of the reason's payers reject transactions today are related to business needs or proprietary format usage. Under HIPAA payers can not "reject" compliant transaction that don't meet their business needs nor can they dictate their own special segment usage. Payers don't have to adjudicate the claim to the submitter's liking but they can't reject it without processing it first. Second, I think the concept of batches will return. The HIPAA claims are sent in transactions (ST to SE) having up to 5000 claims. The paper related concept of batch does not exist. Smart submitters, I suspect, will catch on that multiple smaller transactions will limit their compliance rejection liability. I can see transactions with 100 to 500 claims each as the future norm. Third, HIPAA allows more options to reject/deny input. Unlike today, where payers usually reject in EDI or deny in adjudication, HIPAA permits a more tiered approach. I said "allows" and "permits" because, except for the 835, these ANSI transaction are not mandate by HIPAA. Here is my current understanding of the rejection/denial transactions usable with an 837 transaction. TA1 - This can reject the entire "file" if there is a problem with the ISA (i.e. a file sent it to the wrong payer.) 997 - This can reject an entire transaction (ST to SE) for X12N format problems before claims processing. 824(or 997?) - This can reject an entire transaction for HIPAA compliance issues before claims processing. Unsolicited 277 - This can reject an individual claim for business related issues during claims processing. 835 - This reports payment denial resulting from claims processing. Although the picture is not altogether clear, I think submitters and payers will achieve a workable balance under HIPAA. Payers will accept more data will business problems. Submitters will pay a higher price for format mistakes. Both parties will learn to communicate in a different manner. Robert Barclay EDS - Wisconsin Medicaid HIPAA Team [EMAIL PROTECTED] (608) 221-4746 x3323 ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request.
