Dear Larry:
To add to this interesting discussion, if Payer A in your example treats
Provider X better because of the extra data, would not Payer A be in
violation of 162.925(a)(2) for discriminating against Provider Y who sends
standard transactions?
Peter
Peter Barry
Peter T Barry Company
Ozaukee Bank Building
1425 West Mequon Road
Mequon Wisconsin 53092
(414) 732 5000 (national cell)
[EMAIL PROTECTED]
------------------------------
In a message dated 9/25/2001 8:02:53 AM Central Daylight Time,
[EMAIL PROTECTED] writes:
> Subj: RE: 4010 Transaction vs. HIPAA Compliance
> Date: 9/25/2001 8:02:53 AM Central Daylight Time
> From: [EMAIL PROTECTED] (Larry Watkins)
> Reply-to: <A HREF="mailto:[EMAIL PROTECTED]";>[EMAIL PROTECTED]
</A>
> To: [EMAIL PROTECTED]
>
> While I see Terry's point on the spirit of this, what he is describing is
> more like the 'Optional' data usage that is widely used today. It goes
> something like this:
>
> Payer A receives claims from Provider X and Provider Y. Provider X sends
> data that is marked 'not used'. Provider Y does not. For some reason,
> Provider X gets paid more, or differently, or something. Provider Y asks
> Payer A, "Why did you pay me differently than Provider X?" Payer A
> responds, "Well, I received this data from Provider X that is marked 'not
> used'. I don't require this data, but when I have it I adjudicate
> differently. If you'd like, you can also send this data." In this
> scenario, Provider Y will choose to also use the 'not used' element because
> he understands that he must to get paid appropriately. Suddenly, Payer A
> is, in a sense, requiring the 'not used' element in certain situations to
> give providers what they want.
>
> The end result of this is non-standard use of the standard. We're back to
> needing to know the individual, proprietary rules of each payer in order to
> handle transactions. It also raises some questions. When I send data that
> is 'not used', will the 'traits' (i.e., definition, valid values, length,
> etc.) be standard? Will we not just end up with different 'requirements'
> for different trading partners?
>
> What Payer A needs to do in the scenario above is find a way to get the
> information using the standard implementation, or work to have a change
made
> to the standard. This concept of eliminating 'optional' as a data usage is
> new to the industry. I understand how inflexible it seems, but I believe
it
> is the intent of HIPAA.
>
> Hope this helps,
> Larry
>
>
> -----Original Message-----
> From: [EMAIL PROTECTED]
> [mailto:[EMAIL PROTECTED]]
> Sent: Tuesday, September 25, 2001 7:43 AM
> To: [EMAIL PROTECTED]
> Subject: Re: 4010 Transaction vs. HIPAA Compliance
>
>
> I disagree. I believe if the field is marked "Not Used" you are not
> required to use it. I don't think that is grounds for rejection. If data is
> sent that is the prerogative of the sender, not using the data is the
> prerogative of the receiver.
> The receiver does not have to use, edit or scan the field. To just reject
> the claim would not be in the true spirit of HIPAA.
>
> Thank you,
>
>
> Terry Christensen
>
>
> [ IS Administration Simplification EDI
>
>
> Telelphone: (402)351-6370
>
>
> Fax: (402)351-8025
>
>
> e-mail: [EMAIL PROTECTED]
>
>
>
> Jan Root
> <janroot@uhin To: [EMAIL PROTECTED]
> .com> cc:
> Subject: Re: 4010 Transaction
> vs. HIPAA
> 09/24/2001 Compliance
> 08:26 AM
> Please
> respond to
> transactions
>
>
>
>
>
>
> Chris
> The short answer to your question is that if an element/segment/loop is
> marked
> "Not Used' then it is NOT USED. If a provider is sending you a HIPAA 4010
> 837
> with marital status data then you can reject it as a non-HIPAA-compliant
> transaction. This is sort of what having a national standard is all about:
> everyone doing it the same way. This way you know what to spend your
> limited
> resources on: building a field for marital status on an incoming HIPAA 837
> is a
> waste of your resources.
>
> Anyway, that's my non-official, non-legal opinion!
>
> j
>
> "Graff, Chris" wrote:
>
> > Hello all. We are working on a HIPAA data store and claims processing
> > application. There is a question that has been plaguing our minds here.
> >
> > If you look at the 4010X098 or 4010X096 manuals, there are many fields
> that
> > state "Not Used." Because these fields are not used, I was under the
> > assumption that we should not store this data. For the majority of these
> > fields, this is a no-brainer. Some of the NM1 loops specifically can
> hold
> > information that would never pertain to certain entities within the loop.
> > For instance, there is no reason to keep track of NM111(Entity
> Identifier's)
> > for the submitter loop.
> >
> > Some pieces of data, however, seem to be elements that providers or
> payers
> > may be keeping track of at the moment. One in particular that we found
> was
> > the marital status element, which is on a normal UB-92(locator 16), but
> is
> > listed as not used in the 4010X096 manual. Once we found this difference
> a
> > number of different questions came up.
> >
> > 1. Do we accommodate for this field because it is on the form, and there
> > might be a chance that this particular data element might be passed
> through
> > our processing system?
> >
> > 2. If we accommodate for this field, does that make us not HIPAA
> compliant
> > because we have claims running through the system that contain non-HIPAA
> > compliant data?
> >
> > 3. Should we just accommodate all the possible fields that could appear
> on
> > a 4010 even though it states in the manuals that they are specifically
> not
> > used? Once again would we then be not compliant if we did?
> >
> > Any thoughts on these questions would be greatly appreciated.
> >
> > Thank you,
> >
> > Chris Graff
> > United Wisconsin Proservices
> > (414)226-6022
> > 800-822-8050 x6022
> > [EMAIL PROTECTED]
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