Kepa, I don't think this case is as unlikely as you might think. In fact, I was talking to my eye doctor earlier this week, who has both a private practice as well as belonging to my medical group. He was completely unaware of whether he was a covered entity (in his private practice) which I found interesting in and of itself. But I do believe he falls into the scenario you describe as he does electronic eligibility verification and paper claims submission.
This conversation thread had not started yet, else I would have broached the subject of paper claim/electronic payment with him also. Talking to our own personal physicians can certainly provide some additional insight to the challenges we face in implementing HIPAA. Marchel Burgess DHS - Office of HIPAA Compliance (OHC) (916) 255-5211 fax (916) 255-6047 [EMAIL PROTECTED] -----Original Message----- From: Kepa Zubeldia [ mailto:[EMAIL PROTECTED] <mailto:[EMAIL PROTECTED]> ] Sent: Thursday, October 25, 2001 11:11 PM 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] <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] <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 > > > > > > > > > > ********************************************************************** > > 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. > > ********************************************************************** > 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. > > ********************************************************************** > 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. ********************************************************************** 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.
