Rachel,
Our legal area is not on the same page with the people that say we can do
business without an agreement between the provider and the payer. In fact,
this is a topic that has had EXTENSIVE debate here. The reigning opinion
is that HIPAA will be forcing all payers toward agreements with the
provider, not eliminate them.
What I (and others) have been advocating here is that there is a need for
only two authorizations from the provider. One as a general trading partner
to cover legal and other issues for all transactions except the 835, and a
separate contact for authorization for the 835 (this does not necessarily
mean a hardcopy document). There are people (legal types mostly) that want
separate authorization for each transaction.
An initial authorization is necessary to start the relationship. That will
include an agreement and reference guide that identifies all items about
the payer that are allowed by section 1.1.1 of the HIPAA guides. At that
point, all of the HIPAA transactions to date except the 835 are provider
initiated. If the provider sends 837s, then the provider wants to do
claims. So, once the electronic relationship is setup, the use of the
transaction identifies the request to use the transaction.
The 835 is payer initiated, but only at the request of the provider. To
send it out automatically would not be appropriate. The provider can even
want the 835 without sending an 837, so we don't have any 'trigger' except
the provider's request for the 835. Since the 835 route to the provider is
not a given (it could be a bank that does dollars to data reconciliation
for the provider), only the provider can tell the payer where the 835
should be sent.
Bob
"Rachel
Foerster" To: <[EMAIL PROTECTED]>
<[EMAIL PROTECTED] cc:
tcom.com> Subject: RE: Time-out for terminology
question(s)
01/25/2002
12:11 PM
Please respond
to rachelf
Bob,
I agree. But does this need only belong to the 835 transaction. One could
make this assumption based on other messages to this list that the provider
doesn't get that directly involved with the payer for claims submissions. I
find it difficult to assert that the provider and payer must interact
directly for the 835 but then stay at arm's length for claims and other
HIPAA transactions. This doesn't hang together from an overall process
basis.
So, a question to be answered is the relationship between the provider and
the payer when exchanging HIPAA transactions - the IG's are focused only
very narrowly on a discrete information exchange and the entire process
doesn't seem to be addressed appropriately.
In my opinion, this whole effort is crying for a good process analysis
effort rather than just discrete and disjointed message exchanges.
Rachel
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Friday, January 25, 2002 7:25 AM
To: [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Subject: RE: Time-out for terminology question(s)
There are additional issues with the 835.
HIPAA does not link the 835 with the 837. A provider can ask for the 835
without sending electronic claims.
Providers sometimes send claims through multiple routes. They can even
want to the 835 to return through a different route (like a bank). The
payer must be told when a provider wants an 835 and which route to use.
Sending information down the wrong route can be a privacy problem.
To keep it short - there is NO substitute for provider to payer
communications for the 835.
Bob
Dave Minch
<dave.minch@jm To: [EMAIL PROTECTED]
mdhs.com> cc: [EMAIL PROTECTED]
Subject: RE: Time-out for
terminology question(s)
01/24/2002
06:43 PM
William,
I would guess that, following the pattern that appears to be present for
claim submission which i just finished commenting on, routing of the 835 or
277 would not depend so much on the ISA sender as it would on the 1000A
submitter. The 1000B receiver would have to have my "first-hop" address to
put into the ISA to respond to me.
If that is true, does it imply that i actually need to have a TPA with
every
payer i send information to? (yuck..!!) or if I use a CH, is it their job
to
update the next hop's routing tables (same question that you just asked),
and so forth until the payer's routing tables are eventually updated with
my
submitter id & route information? How does it work today when the paths
are:
Claim: provider ---> prov's CH ---> payer's CH ---> payer
Remittance: payer ---> prov's CH ---> provider (note the omission
of the
payer's CH)
Dave Minch
T&CS Project Manager
John Muir / Mt. Diablo Health System
Walnut Creek, CA
(925) 941-2240
