I am new to this listserv and new to the heathcare industry, so if my comments seem out of line, then please just ignore them as they are being written out of ignorance. My point of reference is from my EDI experience in the chemical manufacturing industry.
It would seem to me that the "non-standard" claims information is really purchase order information. So why try to force-fit it into an 837 transaction? Instead, send the 837 with only the normal claims information and send a separate 850 (purchase order) EDI transaction which would be more suitable for the remaining information. since both trading partners would have EDI capabilities, they should both be able to handle (transmit or receive) the 850. There would need to be some discussion about how to tie the information on the 2 transactions together (eg. Can it be done using reference numbers? If so, what reference numbers?).
What are the pros & cons of this suggestion? I am sure that there are alot more, but the following come to mind:
Pros:
- No need to design 837 transaction attachment for these special items
- Able to integrate 850 data into back-end systems because it could be done with product codes instead of text data, which in turn...
- Minimizes the need to have someone actually read and interpret text data. (This has got to save time and $$$).
- One claim will now need 2 separate transactions
- No governing body would have jurisdiction/responsibility to recommend implementation guidelines so each trading partner could implement the solution in a different manner and actually increase costs.
Stu Joseph
Strategic Systems Solutions
"Christopher J. Feahr, OD" wrote:
Maria and Zon,
Thank you for your (as usual) very thoughtful responses. This represents a
challenging, but critical legal question in Vision... essentially whether a
non-standard, electronic "claim attachment" can be used under HIPAA in a
"claim scenario" that represents the most common type of claim in
vision. And if it can be used, can a payor require it... or require the
use of a web-based DDE system based on its proprietary "attachment"
structure and code sets?Vision payors seem to fall into two categories: simple plans that do not
require any greater detail about the glasses than is conveyed in the 837
using the HCPCS codes and complex plans in which much greater detail is
currently conveyed by complex, proprietary codes in complex, proprietary
transaction structures. The typical OD provider sees MOSTLY the latter and
that "non 837" data represents his biggest headache. Permitting each payor
to cook up its own electronic "attachment" structure and its own
proprietary product codes for this information (the bulk of the "claim"
information for the optometrist) is tantamount to "business as usual" in
vision... i.e., a constantly shifting, non-codable mess for the doctors'
software vendors. The fact that 10% of the information CAN be placed in an
837 is not only of no help, but it actually represents an extra burden...
teasing out the 837-codable data and putting it into a separate 837 text file.I would certainly be in favor of extending Vision's compliance deadline to
permit us to develop standards for this data, but I would not be in favor
of a legal interpretation that effectively held off HIPAA until we got
around to creating suitable standards. In fact, the pressure of HIPAA is
the only thing I can imagine that would INSPIRE the industry to organize
itself and develop the standards. We have been trying to do this without
HIPAA for 20 years and have gotten nowhere. I would not want to see
doctors of optometry prevented from enjoying the same economic benefits of
HIPAA that will accrue to regular medical providers.I am not recommending a hasty "ruling" on this (not that anyone is anxious
to make one!), but we do need a clear and unambiguous statement regarding
what each party (doctor, lab, and payor) can, cannot, and must do in
eyewear insurance transactions after 10-16-02. At the moment, this seems
unclear.Regards,
ChrisAt 11:18 AM 8/23/01 -1000, Zon Owen wrote:
>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.]
>
>
>
>
>**********************************************************************
>To be removed from this list, send a message to: [EMAIL PROTECTED]
>Please note that it may take up to 72 hours to process your request.Christopher J. Feahr, OD
Vision Data Standards Council
http://visiondatastandard.org
[EMAIL PROTECTED]
Cell/Pager: 707-529-2268**********************************************************************
To be removed from this list, send a message to: [EMAIL PROTECTED]
Please note that it may take up to 72 hours to process your request.
**********************************************************************
To be removed from this list, send a message to: [EMAIL PROTECTED]
Please note that it may take up to 72 hours to process your request.
