Would it be useful to employ concrete examples from the HIPAA IGs? If so, perhaps we could start by asking what to do with the Eligibility Benefit Inquiry and Response (270/271) transaction sets. Not knowing any better, I would surmise these are commonly the first transactions used in a typical exchange between a provider and a payer - the start of the "business process." The 004010X092 guide has a number of Business Scenarios and examples. I don't know how typical (or correct) these examples are, but they seem to illustrate various business flows involving combinations of point-to-point and intermediary facilitated interactions.
One of the first questions that pops up is one that Dave Minch brought up (or implied) earlier: how does the NM108-NM109 pair relate to the ISA sender and receiver fields (for point-to-point)? Specifically, what the heck is a "Payer Identification" Code as used in the Information Source HL? We've heard of NAICs and Payer (Plan) IDs used in the ISA, but how do they relate to this thing in the NM1? Given the Information Source (the payer being asked whether a patient is eligible), how do you construct the ISA receiver field in order to tell the VAN or CH where to send the 270? William J. Kammerer Novannet, LLC. +1 (614) 487-0320 ----- Original Message ----- From: "Rachel Foerster" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Friday, 08 February, 2002 08:42 PM Subject: Requirements Gathering Over the last several weeks there's been excellent discussion and "brainstorming" taking place on this list. Now it's time to get more focused, specifically on requirements determination. It seems that I've volunteered to lead the EDI Addressing & Identifiers subgroup responsible for policy and requirements. Accordingly, I'd like to begin the process of collecting requirements. However, I think that a good approach to requirements gathering would be to begin the process of describing the many different scenarios that will need to be addressed for each of these two key activities: EDI Addressing and Identifiers. Towards that end I'd like to request submissions of various scenarios that will need to be supported. Can we begin by using this format: For each scenario: --specify whether it is an EDI Addressing or Identifier scenario --identify the players (e.g., provider, clearinghouse, payer, TPA, PPO, etc.) involved --describe the scenario, e.g., which party initiates the activity, what are the various parties, their roles, the sequencing of their involvement --describe the outcome of a successful scenario After a reasonable period of time I'll try to put each of the scenarios submitted into a formalized template/document so that the more detailed effort of requirements determination can begin. Please start the subject of each message as follows so that I can group and management each message: Scenario: EDI Addressing or Scenario: Identifiers Thanks, Rachel Rachel Foerster Principal Rachel Foerster & Associates, Ltd. Professionals in EDI & Electronic Commerce 39432 North Avenue Beach Park, IL 60099 Phone: 847-872-8070 Fax: 847-872-6860 http:/www.rfa-edi.com
