Frequently claims are also sent from insurance company to PPO (for repricing) or from TPA to PPO and back again. PPOs have not received much press regarding HIPAA but are quite active in the claims payment process. Some of our clients load our rates and provider information onto their own systems and reprice their claims (and inurn send us a claim history file.) Some reprice on our system and then data enter the repriced amount into their system. Some send claims here for repricing either hard copy or through EDI and receive the repriced claim along with an EOR (explanation of repricing.)
Joanne Marquez Senior Director of Account Services Beech Street Corporation (949) 672-1519 phone (949) 672-1144 fax [EMAIL PROTECTED] <mailto:[EMAIL PROTECTED]> � -----Original Message----- From: Jim Moynihan [mailto:[EMAIL PROTECTED]] Sent: Wednesday, October 17, 2001 1:19 PM To: [EMAIL PROTECTED] Subject: RE: Third Party Administrator's Hi Kathy: Long time no speak! Hope you are well. Interesting FAQ. Don't you wish these examples had some more specifics? Anyhow, believe it or not, there are insurance companies that would certainly qualify as health plans, that do subcontract claims processing to TPAs. I can easily see enrollment and premium data going from an employer group to the insurance company and enrollment data going on from the insurance company to the TPA. That seems to be one application that fits the answer to this FAQ. Based on different arrangements for claims funding and payment and other "deals" between plan and TPA there may be additional real world situations where the answer to this FAQ might make sense. Would prefer to know what HHS had in mind rather than speculate like this. Jim -----Original Message----- From: Bakich, Kathryn L. [mailto:[EMAIL PROTECTED]] Sent: Wednesday, October 17, 2001 6:22 AM To: '[EMAIL PROTECTED]' Subject: RE: Third Party Administrator's Jim, I agree with you. However, there is somewhat contradictory advice coming out of the FAQs on the employer/TPA question. Compare the two FAQs cited below. The first FAQ says exactly what you said. The second includes the following sentence: "This means that in cases where the health plan would be required to use a standard transaction within itself, the transaction would have to be standard when conducted between the health plan and its TPA." I can't explain this last sentence. Any help? http://aspe.os.dhhs.gov/admnsimp/q0041.htm http://aspe.os.dhhs.gov/admnsimp/q0162.htm Kathy Bakich The Segal Company Washington DC -----Original Message----- From: Jim Moynihan [mailto:[EMAIL PROTECTED]] Sent: Tuesday, October 16, 2001 6:52 PM To: [EMAIL PROTECTED] Subject: RE: Third Party Administrator's Hi Cindy: 1) It will be interesting to hear the responses of others to this first question. As an employer you are not a covered entity with regard to HIPAA and Workers Compensation "plans" are not qualified health plans and not covered by HIPAA. Given this scenario you might have a problem obtaining HIPAA language in your contracts. 2) If you are self-insured your TPA must support HIPAA transactions or your plan may be subject to fines. This is a "business associate" relationship. Most of the transactions they will have to support connect them to providers for EDI claims processing. As an employer you might want to communicate with the TPA via the enrollment standard (834) but you do not have to use it as an employer. The 834 contains many features not in the HIPAA Implementation Guides to connect your organization to many different benefit administrators. Are you thinking of any other information exchanges between you and the TPA? These would include stop loss premiums, claims funding and payment, stop loss claims submission and payment, etc. There was a Medical Stop Loss Work Group for 2 years at x12 that adapted the standards for employers, TPAs and Stop Loss Carriers but much of that work did not make it into the HIPAA Implementation Guidelines. Marcia McLure and I co-chaired that committee which did its work in the mid-nineties. Few TPAs were willing to step up to the plate at that time. Nonetheless the standards were changed to do what needs to be done should you wish to adopt them. Good luck. Jim Moynihan McLure-Moynihan, Inc. 28720 Canwood Street Suite 208 Agoura Hills, CA. 91301 -----Original Message----- From: Cindy Nielsen [mailto:[EMAIL PROTECTED]] Sent: Tuesday, October 16, 2001 1:40 PM To: [EMAIL PROTECTED] Subject: Third Party Administrator's As a provider of LTC, we fall under the "covered entity" description in the HIPAA regs. Obviously we have to be compliant with the Transactions Standards for 837's and 835's, but I am uncertain about the below two scenerios that deal with employee comp claims and benefits plans. 1. Some of our centers have TPA's that handle our workmens' comp claims. Are we required to have something in our contract with them that references HIPAA compliant verbiage. ( This more than likely deals more with the privacy regulation). 2. We are self-insured but contract with a TPA to administer our employee benefits program. Does our contract with them need to reference HIPAA verbiage? When we transmit info to and from our TPA that contain this benefit info do we need to transmit it the appropriate ANSI X12 format or do the Transaction Standards not apply in this situation? Any assistance you can provide would be helpful. Cindy M. Nielsen Department Director, Information Security Good Samaritan Central Office Phone: 605-362-3252 Fax: 605-362-3991 email [EMAIL PROTECTED] ********************************************************************** 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. ********************************************************************** 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. THIS MESSAGE IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE. 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