Mark,
That sounds like the best plan since we should be closer to the PDF WPC
version by Mid Oct. We'll send out the Dial in information to you after the
Miami meeting concludes.
Michael Cabral
EDS
800 Connecticut BLVD 3rd Floor
East Hartford, CT 06108
* phone: (860) 622 - 4733
fax: (860) 622 - 4774
* mailto:[EMAIL PROTECTED]
www.eds.com
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Friday, September 07, 2001 4:21 PM
To: Cabral, Mike
Cc: Tremblay, Elizabeth K; [EMAIL PROTECTED]; [EMAIL PROTECTED]; Kepa
Zubeldia; [EMAIL PROTECTED]; [EMAIL PROTECTED];
"rachelf]"@ix.netcom.com; [EMAIL PROTECTED];
[EMAIL PROTECTED]
Subject: RE: front end edits and Front End Acknowledgement question
Events (here at Humana) are moving pretty fast, related to implementation
decisions.
Notwithstanding the pace of events (here), I would very much appreciate the
opportunity to attend an Oct or Nov conference call on this matter. Please
forward the number and any required participant code(s) I would need.
I can not guarantee the attendance of WEDI / SNIP folks. I included the
Transactions listserv on the "cc:" as well as some specific individuals,
in hopes they will respond and participate.
Thank you very much for the opportunity to explore this.
Best regards, Mark
"Cabral, Mike" <[EMAIL PROTECTED]> on 09/07/2001 03:44:07 PM
To: [EMAIL PROTECTED]
cc: "Tremblay, Elizabeth K" <[EMAIL PROTECTED]>,
[EMAIL PROTECTED], [EMAIL PROTECTED], Kepa Zubeldia
<[EMAIL PROTECTED]>
Subject: RE: front end edits and Front End Acknowledgement question
Then let me propose this, Currently the workgroup tries to meet a couple
of
times a month on conference calls. We're only meeting next Thursday with a
full agenda so how about sometime in Oct/Nov you and some of the WEDI folks
attend our conference call. After the X12 meeting we'll have a tentative
schedule.
Michael Cabral
EDS
800 Connecticut BLVD 3rd Floor
East Hartford, CT 06108
* phone: (860) 622 - 4733
fax: (860) 622 - 4774
* mailto:[EMAIL PROTECTED]
www.eds.com
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Friday, September 07, 2001 3:32 PM
To: Cabral, Mike
Cc: Tremblay, Elizabeth K; [EMAIL PROTECTED]; [EMAIL PROTECTED]; Kepa
Zubeldia
Subject: RE: front end edits and Front End Acknowledgement question
Mike,
Unfortunately I am not attending the miami X12 meeting. So the forum isn't
an option.
Best regards, Mark
"Cabral, Mike" <[EMAIL PROTECTED]> on 09/07/2001 03:00:42 PM
To: [EMAIL PROTECTED], "Cabral, Mike"
<[EMAIL PROTECTED]>
cc: "Tremblay, Elizabeth K" <[EMAIL PROTECTED]>,
[EMAIL PROTECTED], [EMAIL PROTECTED], Kepa Zubeldia
<[EMAIL PROTECTED]>
Subject: RE: front end edits and Front End Acknowledgement question
Mark,
Are you attending the Miami X12 meeting? If so there is a Forum schedule
to
here industry thoughts on some of the issues that the work group is dealing
with.
Michael Cabral
EDS
800 Connecticut BLVD 3rd Floor
East Hartford, CT 06108
* phone: (860) 622 - 4733
fax: (860) 622 - 4774
* mailto:[EMAIL PROTECTED]
www.eds.com
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Friday, September 07, 2001 2:43 PM
To: Cabral, Mike
Cc: [EMAIL PROTECTED]; [EMAIL PROTECTED];
[EMAIL PROTECTED]; Kepa Zubeldia
Subject: RE: front end edits and Front End Acknowledgement question
Mike, et al,
I would still very much like your thoughts (and the thoughts of any other
team members) concerning the use of the 277 FEA (type/level of edits) and
the location layer from which the 277 would/should issue (within the EDI
layer OR after the EDI layer prior to adjudication layer OR at the front of
the adjudication layer OR multiple layers depending on the edit).
In short, do you think the 277 FEA should be used for
adjudication/pre-adjudication edits or IG compliance edits? Where should
the edit / 277 be done? At the EDI or application/adjudication level?
These questions were discussed and developed on the wedi transactions
listserv, but the responses were not specifically tailored to your new 277
FEA.
Kepa was a part of the discussion (thanks Kepa!), and might still have some
of the more significant emails from the listserv. Otherwise, If you would
like to clarify the question(s), please let me know and I'll forward the
emails.
Thank you in advance for your time and understanding. This is an important
issue for us. We are strongly considering implementing the 277 FEA (prior
to HIPAA mandate, via trading partner agreements) and I'd like the
"designers" thoughts on the use(s) of the "product".
(does this transaction come w/ a bumper to bumper warranty? :-)
Best regards to all, Mark
---------------------- Forwarded by Mark MacIntosh/Louisville/Humana on
09/07/2001 01:59 PM ---------------------------
Mark MacIntosh
09/06/2001 09:41 AM
To: "Cabral, Mike" <[EMAIL PROTECTED]>
cc: [EMAIL PROTECTED], [EMAIL PROTECTED],
[EMAIL PROTECTED], Kepa Zubeldia <[EMAIL PROTECTED]>
Subject: RE: front end edits and Front End Acknowledgement question
(Document link: Mark MacIntosh)
Mike, Thank you for your response. A couple of clarification questions.
In your list of Acknowledgement layers you place the 277 between the 997
and the adjudication system. The 997 and TA1 would likely be issued from
the EDI system. Do you see the 277 issued from the EDI system or the
adjudication system? (coupling question).
The contents of the Front End Edits list you metion would answer the
question I had concerning type of edits you anticipate the 277 would
handle. Could you attach a copy or a portion of a copy of this list?
I would be interested in any examples of the type of edits you
anticipate would be used to generate the 277 draft FEA when used to
reject a claim or lines within a claim.
The Claim Status / Adjustment Reason Code Committee maintains a list
that would be able to function as the "Front End Edit" list so to speak,
so that if and when this Front End guide moves into the HIPAA suite, the
Code List(s) would be flexible enough to meet the changes of industry
quicker than changing an implementation guide via possible NPRM & Final
rule processing.
Regards, Mark
"Cabral, Mike" <[EMAIL PROTECTED]> on 09/05/2001 06:03:26 PM
To: [EMAIL PROTECTED], [EMAIL PROTECTED], "Tremblay, Elizabeth K"
<[EMAIL PROTECTED]>
cc: "Maria Ward (E-mail)" <[EMAIL PROTECTED]>
Subject: RE: front end edits and Front End Acknowledgement question
Mark,
Kepa, Durwin Day, Bob Poiez, Larry Watkins, and myself had a conference
call
with Bruce Horn and the Transactions WG (I believe) several months ago
concerning re-writing some of the opinions on the White paper for Front End
Ack. As I recall this didn't occur as far as I know. Some of the
discussion between Rachel Foerster, Jonathan Showalter and others kind of
contradicted what this work group has been moving towards. The problem is
that the white paper still lists the 824 as a viable Application
acknowledgement. What the work group has started back in 1998 or so is
moving some of the segments of the 824 into the 277 Health Care Information
Response transaction (e.g. AMT and QTY) so that in the health care
environment the Acknowledgement layers would look something like this:
1) 837 Claim Submission
2) 997 and/or TA1 if appropriate
3) 277 Front end acknowledgement
4) claim adjudication system
5) 835 claim remit
The Claim Status / Adjustment Reason Code Committee maintains a list that
would be able to function as the "Front End Edit" list so to speak, so that
if and when this Front End guide moves into the HIPAA suite, the Code
List(s) would be flexible enough to meet the changes of industry quicker
than changing an implementation guide via possible NPRM & Final rule
processing.
Also note that the work group should be completing the Draft for version
004040 of this implementation guide in the next few weeks it does have
some
functions of the version 3070 removed and additional functionality added
that did not exist in the 3070 version.
Also Maria's email has changed from that listed on the X12 web site so I've
copied her in on this.
Don't know that this will answer all of your questions but it is a start
and
maybe the WEDI WG should meet with the X12 WG at some point.
Hope this helps
Michael Cabral
EDS
800 Connecticut BLVD 3rd Floor
East Hartford, CT 06108
* phone: (860) 622 - 4733
fax: (860) 622 - 4774
* mailto:[EMAIL PROTECTED]
www.eds.com
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, September 05, 2001 5:28 PM
To: [EMAIL PROTECTED]; [EMAIL PROTECTED]; [EMAIL PROTECTED];
[EMAIL PROTECTED]
Subject: front end edits and Front End Acknowledgement question
X12N WG5 CLAIMS STATUS group,
I am working with Kay Wyssbrod in defining front end edits and the use of
the 277 Front End Acknowledgement which you have under development.
Having read the WEDI/SNIP white paper on front end edits and some of the
commentary within the 277: Health Care Payer Unsolicited Claim Status ANSI
ASC X12.317 VERSION 003070 DRAFT available at WPC; I would be interested
in any examples of the type of edits you anticipate would be used to
generate the 277 draft FEA when used to reject a claim or lines within a
claim. I would also appreciate any thoughts concerning the location
(within the EDI management system, preceeding or in the adjudication
system) of the edits and the 277 generation. There seems to be a lot of
opinions concerning the nature and location of front end edits. :-))
Your thoughts concerning the use of the 277 under development would be
appreciated.
Regards, Mark
excerpts from WPC draft 277 and WEDI/SNIP white paper follow:
277: Health Care Payer Unsolicited Claim Status (draft)
1.3.1 Claim Application Acknowledgment
A claim application acknowledgment is used as a second level of
acknowledgment
for claims received electronically.
The first level of acknowledgment usually concentrates on the syntax
or structure
of the submission received. For an ASC X12 Health Care Claim (837)
this first
level is a Functional Acknowledgment (997) transaction. The 997
concerns itself
only with the ability or inability of the receiver to understand the
entire claim transaction.
The second level, the application acknowledgment, is a report of the
business validity
and acceptability of the individual claims. The 277 can be used
independent
of the format of the original claim. Usually, the data for this 277 is
generated by a
pre-adjudication editing program. The Application Acknowledgment
identifies
those claims that are accepted for adjudication, as well as those that
are rejected.
The 277 transaction is the only notification of pre-adjudication
rejection of
claims. Claims rejected at this stage of the business process are
never reported
in a Health Care Claim Payment/Advice (835) transaction.
Claims that are missing necessary information are either rejected, or
accepted as
pending at this stage. The actual request for the additional
information is outlined
in the Health Care Claim Status Request for Additional Information
implementation
guide and is considered to be generated by the adjudication system.
The rejection of claims after being pended in the Application
Acknowledgment
277 is accomplished in the 835 transaction. See the Health Care Claim
Pay-ment/
Advice implementation guide for details.
2.1.2 Health Care Payer Unsolicited Claim StatusNotification
In the Unsolicited Claim Status Notification, the reporting is
initiated by the payer,
its agent or its service bureau. An application within the payer's
claim processing
system activates the transaction. Examples include, notification of
receipt into the
adjudication system, a list of claims awaiting final adjudication or a
list of claims
that are suspended. The business function of requesting additional
information
for suspended claims is covered in a separate implementation guide.
SNIP white paper on front-end edits:
One of the reasons for using standard EDI transactions is to provide a
layer of
isolation between the transmission of data and the processing of data
by the
application or adjudication systems. Therefore, front-end edits should
only
relate to EDI transaction syntax and transaction implementation guide
issues.
Application-level edits should be kept separate and communicated using
the
appropriate EDI transaction for each application.
Recommendation: While the levels of edits play an important role in
moving toward
the identification of standardizing the front-end edit process, still
missing is the
standardization of the edits and the messages for those edits. The
standardization of
the reporting mechanisms and the identification of the varying levels
of edits are a
move in the right direction. Those two items alone, however, fall
short of true front-end
edit standardization. For front-end edits to be fully standardized
will require a
consensus definition of the edits themselves
The front-end edits within trading partner systems today vary
depending on the
type of transactions and specific requirements of internal systems.
This is
mostly due to a lack of separation between EDI reporting and
application level
reporting. For example, in some systems, edits for eligibility and
coverage are
pushed to the claims front-end in order to make application edits more
efficient,
or to reduce certain costs. Unfortunately, this makes it impossible to
predict
the acceptance of transactions, and pushes an undue burden to the
trading
partner. Under HIPAA it is now feasible to allow trading partners to
create
predictable front-end edit models that will allow for ease of
processing between
trading partners. With all trading partners adhering to the same
front-end edits,
rejections on the front-end will be greatly reduced.
(See attached file: Front-End Edit White Paper 082901.doc)
"Durwin Day" <[EMAIL PROTECTED]> on 08/24/2001 03:49:49 PM
To: <[EMAIL PROTECTED]>
cc: <[EMAIL PROTECTED]>
Subject: Fwd: FW: X070 draft guide
Attached is the draft guide for the 277 Front End Acknowledgement.
Mike Cabral will be updating the guide with the notes from our recent
meetings (also attached). I will forward your e-mail address to him,
so he can include you in the distribution. The intent of the 277
Front End Guide is to allow payers the ability to report accept and/or
reject of submitted claims before the claims are passed to the
adjudication system. Once claims hit the adjudication system, the 835
transaction would be the appropriate response to the submitter.
Hope this helps.
Durwin
**********************************************************************
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.
