That would be a great Idea!
They had to do the same thing with the UB92.
Tami Leaver
Sr. Application Analyst
Medstar Information Systems
Baltimore Division
410-933-6905
email: [EMAIL PROTECTED]
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| | "Rishel,Wes" |
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| | 09/07/01 03:58 PM |
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| To: "'[EMAIL PROTECTED]'" |
| <[EMAIL PROTECTED]> |
| cc: (bcc: Tami Leaver/WMDC/MedStar) |
| Subject: RE: Situational Data Elements |
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It sounds like what you are saying is that payers need to release an
implementation guide for the implementation guide.
Do you think a lot of payers have done so?
Has UHIN prepared this (and similar) guidance or is it specific to a payer?
-----Original Message-----
From: Jan Root [mailto:[EMAIL PROTECTED]]
Sent: Friday, September 07, 2001 7:53 AM
To: [EMAIL PROTECTED]
Subject: Re: Situational Data Elements
Candice
For things like secondary patient identification numbers (actually any
secondary/additional identification numbers), yes, payers may require that the
provider submit that information (hopefully you've got some easy way for the
provider to get that information in the first place!). The requirement here is
not a syntax requirement (these secondary ID REFs are situational as you point
out). The requirement here is a business requirement. Secondary ID REFs are
situational in the imp guide because not all payers use more than one ID.
Payers may require this information as a business decision if they need it to
find the patient in their adjudication/eligibility/whatever files. This is one
of the key pieces of information that payers should be telling providers: "Put
this number in the NM109 and this other number in the REF using (you pick)
qualifier." The guide is meant to encompass many different situations. In many
ways it is a floor upon which you build your business decisions.
[Also, remember, the primary patient identification number goes in NM108/09.
The REF is only used if you require more than one number to identify the patient
(recalling that Plan/Group Name/Number are carried in SBR03 & 04).]
I always like to think of implementation has having three levels of control
1: Imp guide syntax: this varies from guide to guide, but generally speaking, if
an element is required, then it must be sent. If there is a syntax problem with
a transaction, then it can be rejected on those grounds. Basically, this means
that if something is required then it is sent (realizing that it's not always
easy to figure out when an element is required).
2. Business decisions: If you need 2 numbers to identify a patient or a
provider, then you can make a business decision to require two numbers in your
adjudication process. There is usually room in the 837 (and other transactions)
for more than one identifier for many entities. Here, if a transaction comes in
with only one number and you need two, then it can be rejected as not meeting
your business needs (you can't locate the patient). Just make sure your
provider base knows which two numbers you need and where to put them in the imp
guide (and which qualifier(s) you prefer)
The guide does limit the scope of certain business decisions. For example
your system might be able to handle 100 lines on a professional claim. The 837P
is limited to 50 lines. Hence, all your 100 line claims will now come in on two
claims. You are not allowed to make a business decision to accept 100 line
claims. However, you can still make the business decision that "these services
must be split out this way and these other services must be split out another
way, and these must be lumped, etc., etc.".
3. Customary practices. These are of necessity vague and vary from region to
region, but they still exist and most contracts have something in them about
following customary billing practices.
Hope this helps.
j
Candice Craig wrote:
The 837 Professional IG states (page 49) if no rule appears in the notes
for
a situational element, the item should be sent if available to the sender.
As a payer (receiver) can we require the provider (sender) to collect and
therefore transmit the information? For example, using Loop 2010CA -
Patient Secondary Identification (page 166). This loop is situational if
additional information is required to adjudicate the claim/encounter. If
we
require social security numbers for reporting to the state, can we require
that this loop be always used to collect social security numbers? It is
not
necessary to process the claim, but we must use it when reporting
encounters
to the state.
Thanks for any input!
Candice Craig
GUI Designer/HIPAA Implementation Team
Kent County Community Mental Health
[EMAIL PROTECTED]
This message has been prepared on resources owned by Kent County, MI. It is
subject to the Acceptable Use Policy of Kent County. Candice Craig, CMH,
616-336-8930.
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