I would disagree that format alone constitutes a standard transaction. We define a standard transaction as format as well as content. We plan to reject transactions that are formatted correctly but are not content compliant - up front.
Kris
-----Original Message-----
From: Patricia Peyton [mailto:[EMAIL PROTECTED]]
Sent: Thursday, October 11, 2001 8:52 AM
To: [EMAIL PROTECTED]
Subject: RE: Code Editing
Kris--
I agree...except that the regulations do say a health plan must accept a standard transaction. Thus, for example, a health plan cannot (come 10/16/2002) "reject up front" a properly formatted X12N 837 4010 that it receives.
>>> "Owens, Kris" <[EMAIL PROTECTED]> 10/11/01 10:30AM >>>
I believe most of these answers are really how your organization chooses to
do business - whether you accept into your system and pend for manual
correction or whether you reject up front. The regulations don't specify
which option to take, in fact the regulations don't really care what you do
internally - you can house anything you want in your system internally -
without penalty, the regs only specify what is required when the data leaves
your organization or enters your organization.
At our health plan we generally edit for valid values and if a required
field is omitted or not populated correctly, we reject the transaction to be
resubmitted corrected. Paper claims are a little different. We accept them
into our processing system, but then deny them for missing or invalid data.
This has brought up a HIPAA question for us. This creates a situation where
it will be possible that in an 835 we will supply an invalid code with a
deny pay code - for invalid code value. We feel we have to return the
invalid code so that the submitter knows what they did incorrectly. The IGs
state that we are mandated to use standard coding and yet this situation is
exactly the opposite. What are other organizations doing?
As far as data that we don't need to do business but need to fulfill the
requirements of the IG we are treating it as required data and will reject
the transaction for incompleteness, or invalid values if the data is missing
or incorrect.
Kris Owens
Senior Project Manager - HIPAA Project
Presbyterian Healthcare Services
505/923-8108
[EMAIL PROTECTED]
HIPAA means a higher level of healthcare.
-----Original Message-----
From: Polson, Noelle [mailto:[EMAIL PROTECTED]]
Sent: Thursday, October 11, 2001 7:05 AM
To: [EMAIL PROTECTED]
Subject: Code Editing
I have been trying to get a response to a question that are HIPAA team has.
Martin's question below seems to fall in line with my question since based
on the level of editing one does could determine if the V22 code is excepted
into the internal processing system or not. My question is below. Perhaps
feedback on both Martin's and my question will help many of us. Thanks.
HIPAA ANSI (v4010) Implementation Guides list valid codes or direct you to
an external source. When applying edits to transactions that are received
how are you addressing the following?
1. The IG provides a specific list of codes. When this data element is
REQUIRED:
a. Do you edit to validate that a value is there,
b. Do you validate that the value is one of the ones allowed,
c. Do you validate that the value is valid? (i.e.; 834 - Enrollment,
Loop 2000 - Member Level Detail, Data Element 1069 - Individual Relationship
Code)
d. If the value is invalid, do you reject the transaction or do you
accept the transaction into your processing system and apply a business rule
(i.e.; suspend for manual correction, etc.)?
2. The IG directs you to external sources for some codes (i.e.; zip
codes, ICD9, NDC, etc.).
a. Will you edit to verify that the value is valid or will you just
check to see if a value is present?
b. If the value is invalid, do you reject the transaction or do you
accept the transaction into your processing system and apply a business rule
(i.e.; suspend for manual correction, etc.)?
3. If the field is REQUIRED (i.e.; 834 - Enrollment, Loop 2100 - Member
Residence City, State Zip Code, Data Element 116 - Postal Code) but you do
not need it for business processing purposes to what depth of editing do you
go before allowing the transaction into your processing system?
4. Is there any risk (penalty for non-compliance) to the payer if a
code, that is content compliant but invalid, is passed into the processing
system(s)?
Your feedback would be appreciated.
Noelle Polson
Blue Cross Blue Shield of Florida
HIPAA-AS Corporate Integration
Building DC6-4
4800 Deerwood Campus Parkway
Jacksonville, FL 32246
Phone (904) 905 - 0052 / Fax (904) 997-5399
Email [EMAIL PROTECTED] <mailto:[EMAIL PROTECTED]>
-----Original Message-----
From: [EMAIL PROTECTED]
[mailto:[EMAIL PROTECTED]]
Sent: Wednesday, October 10, 2001 6:07 PM
To: [EMAIL PROTECTED]
Subject: I can't believe I'm asking this question
I am reluctant to pose this question, but need the
validation.
Here goes...
Is "V22" a HIPAA-compliant diagnosis code?
{ } Yes, you dummy. It's right there in the book!
{ }No, It's clearly marked "Additional Digits
Required" in the 2001 ICD-9 manual.
Martin A. Morrison
Project Management Consultant
HIPAA <http://aspe.os.dhhs.gov/admnsimp/>
Implementation/Coordination
Blue Shield of California
<http://www.blueshieldca.com/>
4203 Town Center Bl., Ste. D1
El Dorado Hills, Ca 95762
Ph: (916) 350-8808
Fx: (916).350.8623
[EMAIL PROTECTED]
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