Extending Zon's arguments to situational data elements in a multiple payer
(COB) transaction, we can not reject a transaction because the situation
does not apply to us. A data element that is required for Medicare may not
be required for other payers, but the other payers can not reject the
transaction due to the existence of data in that data element, or the COB
provider to payer to payer approach will not work.
On a practical note, the payer's principle objective in their claims
processing systems is to pay claims. Why should it matter to any payer what
data is in any other data element than those the payer needs to pay the
claim? Should it be significant what is in any other data element? I think
not, except under the condition where a provider is paid differently because
of the existence of data in not used fields which, I expect, most of us
recognize as a potential HIPAA violation. The resources (systemic and
personnel) needed to code, validate, reject, and resubmit transactions due
to extraneous values in areas that are not significant to paying the claim
could be significant. Further, I believe the effort is a disservice to the
provider, especially when the provider or another party in the process
failed to initialize insignificant parts of the transaction, or used a
different initialization routine than we were expecting (a system might not
allow blanks in numeric fields.)
-----Original Message-----
From: Zon Owen [mailto:[EMAIL PROTECTED]]
Sent: Tuesday, September 25, 2001 1:53 PM
To: [EMAIL PROTECTED]
Subject: Re: 4010 Transaction vs. HIPAA Compliance
Aloha!
I would generally agree (1) that it would usually be pointless to include
anything in the "Not Used" items, and that (2) it could still be a business
decision as to whether or not a receiver rejects it, as long as there is
nothing in a trading partner agreement that requires it, and as long as it
is not used. Given that, I could still see a couple of situations where you
might have a legitimate need to have it present:
First, it could be a non-HIPAA claim. E.g., it could be for a non-covered
payer, such as a Property & Casualty insurer. Or it could be for a service
not considered to be health care under HIPAA, but otherwise billable via the
837.
Second, it could be a multiple payer claim in which a secondary or later
payer was not covered by HIPAA. HIPAA provides for saving and forwarding
any information on a multi-payer claim that could be of use to a later
payer. If such a subsequent payer is not covered by HIPAA, they could have
some data requirements that were quite compatible with the X12 standard, but
not with the HIPAA Implementation Guide.
While this sounds a bit hypothetical, I imagine that some organizations will
see these cases and others. So how do we handle such combinations of HIPAA
and non-HIPAA payers?
- Zon Owen -
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