Jan,
I thought you did a very nice job laying out how information that is
needed by the payer's system to adjudicate a claim that is not part of the
required segments of the 837 transaction can be accommodated by the
situational segments (e.g. since the NPI won't be ready in time, a system
may require a proprietary provider number which would have to be placed in
the REF segment in that loop). Wes then asked about an implementation
guide for the implementation guide and that is what I responded to. Payers
could put out a big complex document that would describe what all doctors
and pharmacies and hospitals and ancillary providers would need to put into
various situational segments but it seems more efficient to me to handle
this in a more simple trading partner agreement. This would be like
saying, "You know that provider number you use when you submit claims to us
now. We'll still need that number to process your claim and we'd like you
to put it in the REF segment of this loop."
George Mueller
IT Advisor
Anthem West BCBS
(303) 831-2402
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Jan Root
<janroot@uhin To: [EMAIL PROTECTED]
.com> cc:
Subject: Re: Situational Data Elements
09/10/2001
10:12 AM
Please
respond to
transactions
George
What would a TPA do here?
j
[EMAIL PROTECTED] wrote:
> 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
>
> CONFIDENTIALITY NOTICE: This email messsage, including any attachments,
is
> for the sole use of the recipient(s), and may contain confidential and
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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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