Kepa,
COB is routine, but the information is being provided by the provider and not the
participant. Just because a provider states there is or isn't other coverage, is not
the authoritative final response. A plan may require that the participant assert that
there is no other coverage. Also, a plan may have quality controls to check for
fraud and/or just perform routine audit of claims. The point, I'm trying to convey
is that there is other information that may be needed beyond what comes in an
electronic response. 90+% of the time, the information will be sufficient. I would
consider these requests to fall into the categories of either "attachments" or
"requests to parties besides the provider". I believe I understand what Stanley
meant, but I just want to make sure that Stanley's comment is not misconstrued to mean
that HHS is advocating that a plan is required to forget about its fiduciary duties
and pay an electronic claim just because it has all the necessary elements. I can
assure you that there are people who would take this position, if not clarified. I
would note that any additional requests or steps are not limited to electronic
processes and would apply to paper claims.
David
>>> [EMAIL PROTECTED] 08/27/01 12:13PM >>>
David,
COB? That sounds routine to me. In fact the claim includes this
functionality. Are you asking for something more specific?
Kepa
David Blasi wrote:
>
> Stanley,
>
> What I'm gleaning from your comment is that if detailed claim information is needed
>every time, that it should be a part of the standard electronic claims submission.
>Requests to add should go through the DSMO. I just want to clarify that your comment
>would not apply to asking for medical records or other information which is needed
>for (1) routine fraud detection; (2) medical necessity determinations; (3) E&I
>determinations (4) subrogation; (5) COB, etc.
>
> Thanks
>
> >>> [EMAIL PROTECTED] 08/27/01 09:30AM >>>
> I just came back from vacation and saw this. I am uncomfortable with this statement
>for several reasons.
>
> First, if the "non-traditional" information is necessary on every vision claim, it
>should be considered claim information and not attachment information. If it is
>claim information, it can only be submitted as part of the standard. If it is not
>part of the standard, it cannot be submitted electronically, and providers cannot be
>forced to send it on paper or any other way. A health plan must be able to process
>claims electronically using the standard.
>
> Attachment information should only be used for non-routine claims.
>
> Stanley Nachimson
> Office of Information Services, CMS
> 410-786-6153
>
> >>> [EMAIL PROTECTED] 08/20/01 04:35PM >>>
> Dear Group,
> I'm beginning a conversation with a large commercial vision payor and I was
> planning to make the following statement to them. I would like to know if
> it is factually correct, as written. If I'm wrong or even "slightly off
> base" regarding any part of it, I would appreciate your comments:
>
> "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". 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. 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. A second alternative would be for [VISION PAYOR] to adjudicate
> claims without this information."
>
> Thanks very much for your feedback.
> -Chris
>
> Christopher J. Feahr, OD Vision Data Standards Council
> Executive Director http://visiondatastandard.org
> Cell/Pager: 707-529-2268 [EMAIL PROTECTED]
>
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