Chris,
See my "Z-Notes" below.
Maria,
Please check this reasoning and/or add some of your own.
Thanks!
- Zon -
(808)597-8493
----- Original Message -----
From: "Christopher J. Feahr, OD" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>; <[EMAIL PROTECTED]>
Sent: Monday, August 20, 2001 10:35 AM
Subject: Is this statement correct? [RE: Vision claim]
> "If [VISION PAYOR] requires "non-traditional-claim" information (e.g.,
> specific details about the frame, lenses, coatings, spectacle-Rx, etc.,
> commonly included in the doctor's "purchase order") to process/pay a
claim,
> then the totality of that information plus the 837-information would
> constitute "The Claim".
[Z-Note: I'm not aware that anyone currently agrees on what a "claim" is,
so I can't agree that we agree on this as an industry. For example, many
attachment-related data items have been included in the 837 and other
standards, such as the Institutional EMC (UB-92) flat file, simply because
it was easier to include them there than it would have been to develop a
separate standard for them. And one of the major wish list items at X12N is
to redistribute the data content across the X12 and the claim attachments
standards in such a way as to move a lot of this stuff out of the 837 and
into the attachments standard. But we need a claim attachments standard in
place before we can do that, and it might also take several years to
accomplish such a redistribution.]
> Since a HIPAA-standard does not exist for the
> information normally found on a lab purchase order, it will not be legal
> after 10-16-02 for [VISION PAYOR] to receive that information
> electronically.
[Z-Note: I'm not sure that I would agree, since it's not clear whether or
not there would be anything to prevent you from sending attachment-related
data electronically prior to the development and implementation of an
attachment substandard specific to vision, as long as you don't call it a
"claim". Once such a vision-specific substandard was available, then you
might be constrained.
More broadly, you need to understand that we expect the initial claim
attachments standard to include only a handful of the possible attachments.
Others will be added over a period of several years, as resources become
available to work on the. But my presumption is that payers and providers
will continue to be able to request and submit attachments, either on paper
or electronically, until such time as the type(s) of information that they
are interested in is included in one of the attachments substandards. Once
that has happened, they would have to use the adopted claim attachments
standard. But, as far as I know, paper attachments could still be used,
since few providers are automated in a way that supports the use of
electronic attachments. A payer just wouldn't be able to require the paper
attachment if the equivalent information was provided electronically.]
> Information necessary for routine claim adjudication that
> cannot be placed into a standard "837 claim" or into one of the standard
> "claim attachments" (proposed by HL7 and the Claim Attachment Committee)
> will have to be sent to the vision plan or its exclusive business agent,
> via paper.
[Z-Note: As noted above, it's not clear that you would be precluded from
doing this electronically as long as the type of attachment used wasn't
supported by the then-current Attachments standard.]
> A second alternative would be for [VISION PAYOR] to adjudicate
> claims without this information."
[Z-Note: True.]
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