Martin, I don't share your perception that a payer can choose **not** to receive an electronic claim from a non-participating provider. I haven't seen anything in the statute or the electronic transaction rule that gives a payer the option of **not** receiving a HIPAA electronic transaction from a non-par provider. If you get them on paper today, you can and should anticipate getting them electronically in the future. Functionally, this is no different than a claim or other transaction on paper coming in through your company's mailroom or appearing on your fax machine.
Furthermore, there is NO requirement for a trading partner agreement under HIPAA. � 162.915 Trading partner agreements. A covered entity must not enter into a trading partner agreement that would do any of the following: (a) Change the definition, data condition, or use of a data element or segment in a standard. (b) Add any data elements or segments to the maximum defined data set. (c) Use any code or data elements that are either marked ��not used�� in the standard�s implementation specification or are not in the standard�s implementation specification(s). (d) Change the meaning or intent of the standard�s implementation specification(s). If you strongly disagree with this potential scenario and whether or not your organization is obligated to at a minimum receive the electronic interchange and enclosed transaction(s) in through your electronic front door then I strongly recommend that you consult with your corporatation's legal counsel on the issue. >From the Electronic Transaction Final Rule: � 162.925 Additional requirements for health plans. (a) General rules. (1) If an entity requests a health plan to conduct a transaction as a standard transaction, the health plan must do so. (2) A health plan may not delay or reject a transaction, or attempt to adversely affect the other entity or the transaction, because the transaction is a standard transaction. (3) A health plan may not reject a standard transaction on the basis that it contains data elements not needed or used by the health plan (for example, coordination of benefits information). (4) A health plan may not offer an incentive for a health care provider to 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 -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Tuesday, May 28, 2002 5:23 PM To: [EMAIL PROTECTED] Subject: RE: TA1 responding to non-participating health care providers Whoa!, Bill... You make it sound as if payers will be obligated to open their gateways, carte blanch, to any who wish to direct a file our way. While there may, in the past, for some payers, have been requirements that a provider must be "participating" in order to submit their claims electronically or otherwise capitalize on their EDI investment(s), that in no way means that we have to take in a file from entities we haven't entered into a Trading Partner Agreement with and set up in our system(s)(participating or not). If a provider were to unilaterally determine how to route data to us and get it wrong, it would increase the chance that we might be receiving another carriers information in error. There is also the issue of our not being able to process their information or inquiry as certain basic identifiers (part of the TPA) were not used or used correctly. I know it flies in the face of admin simp., but, until all the identifiers are finalized, we will have TPA's that look a lot like what we have today. If I have missed something in this thread or misinterpreted your intent, please accept my apologies in advance. _____ Martin A. Morrison Project Management Consultant HIPAA Implementation/Coordination Blue Shield of California 4203 Town Center Bl., Ste. D1 El Dorado Hills, Ca 95762 Ph: (916) 350-8808 Fx: (916) 350-8623 -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Tuesday, May 28, 2002 2:59 PM To: WEDi/SNIP ID & Routing Subject: TA1 responding to non-participating health care providers Just one more reminder - this time from the EDI-L mailing list - that we have to keep in the back of our mind something almost no other industry has wrestled with in EDI before: Unsolicited Transactions, � la Open-EDI, from non-participating providers. Payers will have to be prepared for taking in anything coming along from providers - if they would have taken paper before, they can't put roadblocks up discriminating against the equivalent Federally mandated HIPAA standard transactions! Not only will they have to make available an open portal for receiving electronic claims and eligibility inquiries (advertised in our Healthcare CPP Registry), but they will have to make sure their translators can accommodate ISA senders they've never seen before. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Rachel Foerster" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Tuesday, 28 May, 2002 01:32 PM Subject: RE: [EDI-L] TA1 On the other hand, the TA1 may become a useful/important ack in health care under HIPAA since it's entirely possible that a payer/health plan/insurance company could receive an unsolicited interchange containing health care claim transactions from non-participating health care providers. In this scenario, the translator won't know about the sender in advance, but the receiver needs to know it's received an interchange from an unknown sender and then take appropriate action. 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 -----Original Message----- From: DPR [mailto:[EMAIL PROTECTED]] Sent: Sunday, May 26, 2002 11:19 AM To: [EMAIL PROTECTED] Subject: [EDI-L] TA1 In my experience, I have never found anyone who wanted or cared about a TA1 segment. About all it says is roll call "I'm here'. There are quite a number of translators who don't even know what a TA1 is and choke if one gets through. So save your time and money and forget about the TA1. If the ISA/IEA is bad, you will never get a 997 in return. Dennis Robinson
