You have described our situation exactly. It is what we do. There is no relationship between the medium in which we receive the claim and the medium in which we send out the electronic 835 or the paper EOP/EOB.
Kris Owens
Senior Project Manager - HIPAA Project
Presbyterian Healthcare Services
505/923-8108
[EMAIL PROTECTED]
HIPAA means a higher level of healthcare.
-----Original Message-----
From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]]
Sent: Friday, October 26, 2001 12:11 AM
To: [EMAIL PROTECTED]
Subject: Re: Issue from a recent conference
I know this is not a very likely case, but a provider could choose to
not send electronic claims at all, and still be a covered entity under
HIPAA. Perhaps because the provider does electronic eligibility
transactions. Perhaps because the provider desires to receive
electronic remittance advice.
If a provider desires to conduct a transaction, such as remittance
advice, as a standard transaction, the health plan may not refuse to do
so. Nowhere in HIPAA it says that a provider must submit an electronic
claim before he can receive electronic remittance advice.
Oh, well, I am sure this email did not make very many friends, and I am
going to be flamed for this, but, I would like to understand where some
of the logic in the messages below fits in HIPAA.
As a common practice today, there are many payers that will send 835
transactions to providers that desire to receive 835s. In most of these
cases, once a provider makes that choice, all the remittance advices are
reflected in 835s, whether the claim was submitted on paper or
electronic. I am not saying everybody does that, but as far as I know,
most of the 835 files that I have seen also contain payments on claims
that were submitted on paper. I don't see that practice changing with
HIPAA. In fact, I think that if a provider desires to receive all its
remittance advices electronically, the payer must do so. I don't think
the payer can pick and choose certain payments to go on paper remittance
advice and others to go on 835. At least as I understand the HIPAA
regulations.
Dissenting opinions are welcome.
Kepa
[EMAIL PROTECTED] wrote:
>
> I strongly disagree. 162.925 (the rule you quote as authority) is not
> applicable to providers who conduct PAPER submissions. 162.925 et al are
> only applicable to providers who conduct (submit) EDI transactions. The
> definitions on applicability are clear on this:
>
> 50365 Federal Register / Vol. 65, No. 160 / Thursday, August 17, 2000 /
> Rules and Regulations
> � 160.102 Applicability.
> Except as otherwise provided, the
> standards, requirements, and
> implementation specifications adopted
> under this subchapter apply to the
> following entities:
> (a) A health plan.
> (b) A health care clearinghouse.
> (c) A health care provider who
> transmits any health information in
> electronic form in connection with a
> transaction covered by this subchapter.
>
>
> "Tucci-Kaufhold, Ruth
> A." To: "'[EMAIL PROTECTED]'"
> <Ruth.Tucci-Kaufhold@u <[EMAIL PROTECTED]>
> nisys.com> cc:
> Subject: RE: Issue from a recent conference
> 10/25/2001 02:55 PM
> Please respond to
> transactions
>
>
>
>
> The provider can submit paper and request that a payer provide an 835
> remittance. The rule allows this ... the health plan cannot refuse to
> provide that provider with the 835 if that provider asks the health plan to
> do so. (p. 50469 ss162.925)
>
> The issue of the lack of data can be solved by the payer requiring those
> data elements from the provider ... that is permissible.
>
> Ruth Tucci-Kaufhold
> UNISYS Corporation
> 4050 Innslake Drive
> Suite 202
> Glen Allen, VA 23060
> (804) 346-1138
> (804) 935-1647 (fax)
> N246-1138
> [EMAIL PROTECTED]
>
> -----Original Message-----
> From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
> Sent: Thursday, October 25, 2001 2:41 PM
> To: [EMAIL PROTECTED]
> Subject: RE: Issue from a recent conference
>
> I haven't been fully following this thread, but on the question of a
> submitter "requiring" an 835 response from a paper submission, I disagree
> strongly.
>
> Paper transaction submissions are exempt from HIPAA transaction standards.
> HIPAA transaction requirements are expressly limited to EDI transactions.
> The content (lack of) of the paper claim submission would make a compliant
> 835 EDI response difficult if not impossible.
>
> I fail to see how a submitter, who (at their option, by sending 'paper')
> 'exempts' a transaction from HIPAA, may 'un-exempt' the same transaction
> once it reaches the payor, by requiring an EDI response from the payor.
> Where is this written?
>
> Lastly, a non-compliant EDI response to a paper submission, would place
> only the payor in violation of HIPAA. To permit a submitter to force a
> payor to respond to a paper submission with a non-compliant EDI
> transaction, thereby risking violation and fine, where the reason for the
> non-compliance is solely due to the format and content of data presented by
> the submitter, is absurd.
>
> "Hauser, Tarry"
>
> <THauser@mahealt To:
> "'[EMAIL PROTECTED]'"
> hcare.com> <[EMAIL PROTECTED]>
>
> cc:
>
> 10/25/2001 02:31 Subject: RE: Issue from a
> recent conference
> PM
>
> Please respond
>
> to transactions
>
> Thanks all....I do think your approach Steve - and that of Jonathan -
> is/are
> the most reasonable given current circumstances. Though it is true that it
> does raise more questions.
>
> -----Original Message-----
> From: Hanson, Steve [mailto:[EMAIL PROTECTED]]
> Sent: Thursday, October 25, 2001 1:24 PM
> To: '[EMAIL PROTECTED]'
> Subject: RE: Issue from a recent conference
>
> We assume that this is a matter that individual providers must work out
> with
> payers, and are modifying our provider demographic data to include controls
> for this. We also assume that this control applies regardless of whether
> or
> not we receive an 837; that is, we must issue an 835 to a provider who has
> previously requested this method of payment for both 837 and paper claim
> submissions.
>
> Unfortunately, I can't tell you what parts of the regs we were looking at
> when we reached this conclusion.
>
> Steve Hanson
> Senior Product Technical Consultant, The TriZetto Group, Inc.
> "Pluralitas non est ponenda sine necessitate" - Ockham's Razor (14th
> century)
> for which my favorite corollary is:
> The simplest solution that is both necessary and sufficient is best.
>
> > -----Original Message-----
> > From: Hauser, Tarry [SMTP:[EMAIL PROTECTED]]
> > Sent: Thursday, October 25, 2001 8:30 AM
> > To: '[EMAIL PROTECTED]'
> > Subject: Issue from a recent conference
> >
> >
> >
> > "There did not seem to be a definite answer on how we know that we should
> > send an 835 transaction back when we receive an 837. At one point there
> > was to be a routing # if the Provider wanted the 835 back. However, there
> > is nothing in the data field such as a routing # to know."
> >
> > This question cam back to me after one of our own attended an SPBA
> > conference. Do we have an answer for this anywhere in the regs?
> >
> > Tarry L. Hauser
> > Applications Specialist
> > Medical Associates Health Plans
> > 700 Locust Street Ste 230
> > PO Box 5002
> > Dubuque, IA 52004-5002
> > (319)584-4830
> > FAX (319)556-5134
> >
> >
> >
> >
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