Kepa, Not exactly. A previous responder also quoted from the Transaction Rule preamble, page 50336, third column, item iv. --------------------------------------------------------------------------------------------------------------------- iv. Comment: Several commenters questioned whether a health plan will be required to respond to an ASC X12N 276 request from a health care provider who did not have a business arrangement with the health plan.
Response: A health plan may not refuse to process a transaction simply because it is a standard transaction. Whether a health plan may refuse to process a transaction on other grounds may depend upon the particular business agreements the health plan has with the sender. Health plans may have contracts that require them to process out of service area transactions. Use of a standard transaction does not create a relationship or liability that does not otherwise exist. A health plan would not be required by these rules to respond to such a request from a health care provider with whom it does not have a business arrangement. ---------------------------------------------------------------------------------------------------------------------- The excerpt above (though found in the section referring to 276 / 277) appears to apply to all transactions based on whether or not you have a business arrangement. All Implementation Guides recommend the use of and discuss the limitations of Trading Partner Agreements. In addition, certain transactions like the 270 / 271, 276 / 277 require that you verify whether or not the sender should have access to the information they are requesting. If we do not have a business arrangement with a provider, we would respond in kind with the appropriate error message. The 837 does not have a response document to notify providers in such a case. In addition to gaining consensus on what the Rule really means, I would like to know if other Payors are planning on accepting transactions from non-participating providers? Jon Fox Independent Health CONFIDENTIALITY NOTICE. This e-mail and attachments, if any, may contain confidential information which is privileged and protected from disclosure by Federal and State confidentiality laws, rules or regulations. This e-mail and attachments, if any, are intended for the designated addressee only . If you are not the designated addressee, you are hereby notified that any disclosure, copying, or distribution of this e-mail and its attachments, if any, may be unlawful and may subject you to legal consequences. If you have received this e-mail and attachments in error, please contact Independent Health immediately at (716) 631-3001 and delete the e-mail and its attachments from your computer. Thank you for your attention. >>> [EMAIL PROTECTED] 01/14/02 08:42PM >>> Jonathan, The Act says: 1175 (a) (1) IN GENERAL - If a person desires to conduct a transaction referred to in section 1173(a)(1) with a health plan as a standard transaction -- (A) the health plan may not refuse to conduct such transaction as a standard transaction; (B) the insurance plan may not delay such transaction, or otherwise adversely affect, or attempt to adversely affect, the person or the transaction on the ground that the transaction is a standard transaction; and (C) the information transmitted and received in connection with the transaction shall be in the form of standard data elements of health information. Does that answer your question? Kepa Jonathan Fox wrote: > > Kepa & Peter, > > Is there text from the Rule that can substantiate one way or the other? > > Jon > > CONFIDENTIALITY NOTICE. This e-mail and attachments, if any, may contain >confidential information which is privileged and protected from disclosure by Federal >and State confidentiality laws, rules or regulations. This e-mail and attachments, >if any, are intended for the designated addressee only . If you are not the >designated addressee, you are hereby notified that any disclosure, copying, or >distribution of this e-mail and its attachments, if any, may be unlawful and may >subject you to legal consequences. If you have received this e-mail and attachments >in error, please contact Independent Health immediately at (716) 631-3001 and delete >the e-mail and its attachments from your computer. Thank you for your attention. > > >>> [EMAIL PROTECTED] 01/12/02 01:57PM >>> > Peter, > > Let me add a little... (in parenthesis) > > > The general rule means that if you accept any claims (even paper claims or DDE) >from nonparticipating, > > you have to accept standard electronic claims. > > Kepa > > [EMAIL PROTECTED] wrote: > > > > Dear Jonathan: > > > > The general rule means that if you accept any claims from nonparticipating, > > you have to accept standard electronic claims. > > > > If you do not accept any claims whatever from nonparticipating providers, it > > is my understanding that you would not have to accept standard electronic > > claims. > > > > 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 1/11/2002 8:37:58 AM Central Standard Time, > > [EMAIL PROTECTED] writes: > > > > > Subj: Non-par providers > > > Date: 1/11/2002 8:37:58 AM Central Standard Time > > > From: [EMAIL PROTECTED] (Jonathan Fox) > > > Reply-to: <A HREF="mailto:[EMAIL PROTECTED]";>[EMAIL PROTECTED] > > </A> > > > To: [EMAIL PROTECTED] > > > > > > Clarification/verification needed. > > > > > > Based on the following excerpt from the Final Rule: > > > > > ----------------------------------------------------------------------------- > > > - > > > �162.925 Additional requirements for health plans. > > > (a) General rules. > > > > > > (1) If an entity requests a health plan to conduct a transaction as a > > > standard transaction, the health plan must do so > > > > > > > > ----------------------------------------------------------------------------- > > > > > > > > > We had a question about non-participating providers. We currently do not > > > accept electronic claims from non-par providers, and it looks like that > > will > > > have to change by the compliance date. Does this present any problems for > > > other payors out there? > > > > > > Thanks. > > > > > > Jon Fox > > > eCommerce Analyst > > > Independent Health > > > > ********************************************************************** > > 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.
