George, The HIPAA purpose of the 835 is for payment and remittance advice. This also includes a non-payment notification to the provider.
However, there are a number of other reasons why a claim could "reject" such as the patient or provider being unknown to the payer, or missing a HIPAA situationally required element, or simply because it is no longer covered. Many of these cases are "business" type of rejections for an otherwise perfectly compliant (both X12 and HIPAA syntax requirements) transaction. So, the fact that the transaction went through the translator without errors is not enough to determine it is an acceptable transaction. Many other issues are involved. As opposed to the 270/271 or 276/277 or 278/278 transaction pairs, the 835 is not "paired" with the 837 as a response transaction. One 835 may contain claims submitted on multiple 837s or even on paper. The claims submitted in one 837 can be adjudicated in multiple cycles and reported in multiple 835s. There is not a 1:1 relationship between the contents of an 837 and one 835 transaction. Whereas HIPAA requires the receiver of a 270 to respond with a 271, or the receiver of a 276 to respond with a 277, the relationship between the 837 and the 835 is not so tight. It is possible that a provider may send 837s and still request paper remittance advice, or send paper claims and request 835s. One of the big missing links in HIPAA is that there is not a mandated standard for "rejected" or "returned" transactions. The state of NJ has taken the leadership in this area by requiring these transactions acknowledging the response or rejection, but the federal HIPAA does not have such mandate. So, it is perfectly possible for a payer to receive an 837 and report the rejected/returned claims with some sort of electronic report in "print format" or with a paper report sent in the mail (USPS mail) or with another X12 transaction such as the "unsolicited" 277 or 824 (not HIPAA standards) or, depending on where in the adjudication cycle it is, it could be returned "unpaid" as part of an 835. But there is not a requirement to return these "unpaid" rejections in the 835. As long as the adjudication systems are very different from each other, it would be very difficult to implement such requirement in HIPAA. Some may choose to return it in the 835, others may choose to implement an unsolicited 277, or the 824 "application advice" transaction. Others may return it via a paper printout. Others yet may, heaven forbid, just drop the claim to the "bit bucket" and just ignore it. As far as HIPAA is concerned, they accepted the claim in a standard 837, so they are OK. In fact, HIPAA, arguably, does not require a payer to "pay" the transaction. This falls more into the realm of "prompt pay" legislation. If the transaction is not paid within a reasonable time frame (15-21 days?) then the provider should be notified whether they are or are not going to get paid and why. Some prompt pay legislation could, conceivably, require the payers to use HIPAA standard transactions for such notifications, but I am not aware of this as a general requirement from the states (yet). This is clearly a hole in the system. However, HIPAA has a mechanism that can help discover claims that have fallen into the "hole". A payer that receives a 276 claim status inquiry is required to respond with a 277 claim status response. So, if a provider sends a claim, the claim is rejected/returned by the payer with a mechanism that is not good for the provider (e.g. the provider wants an unsolicited 277 and this payer only sends paper reports in the USPS mail) then the provider, after some reasonable time, could probe the payer for the claim status with a 276 and the payer would respond with a 277. If the claim in question was rejected/returned by the payer, the claim status response would reflect it. And if the response says "I don't know about that claim ever reaching me" at least the provider has an indication that something is amiss and should start further investigation. But unless, as an industry, we agree to some standard for these responses and we implement the standard, we are left with this big hole to cover. Some will cover parts of it with the 835, others will use the unsolicited 277, others the 824, others a combination of those. None of them are mandated by HIPAA for this purpose. Sounds like an opportunity to do something in the industry as a voluntary consensus implementation, without waiting to have a mandate. The problem is serious. For more info, take a look at the "Front End Edits" white paper of SNIP. Kepa On Friday 05 April 2002 02:53 pm, George Kaye wrote: > If an 837 claim is received and passes the ANSI syntax editing in our > translator, then is forwarded on to our application systems which then find > some errors that we want to reject back to the provider: 1. Is that > electronic rejection response mandated to be an 835? > 2. Does that rejected claim need to be maintained in our history of > rejected claims in order to be able to respond to a 276 claim status > inquiry? To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=business and enter your email address. The WEDI SNIP listserv to which you are subscribed is not moderated. 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