Unless I'm mistaken, I thought this is the area where TPA's come into
play.
George Mueller
IT Advisor
Anthem West BCBS
(303) 831-2402
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"Rishel,Wes"
<wes.rishel@ga To: "'[EMAIL PROTECTED]'"
<[EMAIL PROTECTED]>
rtner.com> cc:
Subject: RE: Situational Data Elements
09/07/2001
01:58 PM
Please respond
to
transactions
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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