David,
Understanding what you are saying, it seems that you are not talking
about a HIPAA transaction at all. You are asking the insured to prove
that they have or do not have other coverage. That is not a HIPAA
transaction. For example, asking for proof that the dependent is in
fact a full time student is additional information that is not
contemplated by HIPAA. There are many more instances like this.
But this was not evident in your message. You just mentioned COB as a
reason to ask for additional information. There is routine COB, and
there are these other auditing functions. Maybe you classify them as
COB, but it may be best to describe them under audit or fraud and abuse
or another category.
Thanks for the clarification.
Kepa
David Blasi wrote:
>
> 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 elemen!
ts. 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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