Jim,
Sorry for the late replies, I have been out of the office.
I did in fact error with my original solution to use the 997.
Jan, In the past, pre-HIPAA, the "Unexpected Segment" message has been used
as a method to solicit a phone call from the sender of the invalid
transaction for business practices. I agree with Jan that this is
inappropriate processing for HIPAA base on notes in the actual data element
description for the 997 transaction.
I don't agree with the use of the 277 Unsolicited transaction. This
solution could be met with mixed results based on how each dental provider's
system are programmed for the receipt of a 277 transaction.
I agree with Jan's assessment that this is a Business Issue.
I can offer the following suggestion:
1) Create a field that will indicate to your front-end claims system that
a Dental Predetermination of Benefits has been received.
2) You have many options at this point
2.1) Create a report that is distributed to your user/client staff
who make telephone calls
2.2) Automatically send a letter to the Dental provider or use
another mechanism to communicate such as, VRU, Fax, or email.
A plan cannot reject this transaction since the transaction complies with
HIPAA, however, a plan is not required to bring this claim into their claim
processing system.
The interesting part of the HIPAA transaction for this scenario will be how
a 276 Transaction is processed on this type of claim and the plan did not
bring the claim into their claims processing system. .
Hope
> -----Original Message-----
> From: J.G. [SMTP:[EMAIL PROTECTED]]
> Sent: Friday, January 18, 2002 2:11 PM
> To: [EMAIL PROTECTED]
> Subject: RE: Predetermination of Dental Benefits
>
>
> I think we may try to go ahead with Mike's or Jan's suggestion of using
> either the 101 or 110 adjustment reason code initially. I'm concerned
> that
> these will result in phone calls instead of conveying what we really want
> to
> convey. The 101 suggestion seems to indicate that we expect to pay $0
> when
> we may actually pay something when the claim is filed. But this was also
> what we came up with. The 110 may make it seem that we thought it was a
> claim instead of a predetermination, but may actually get the point across
> to some of the providers.
>
> Therefore we will probably go ahead and request a new code, and when/if
> it's
> issued we will simply have to make a quick update to a table on our
> system.
>
> My concern about unsolicited claims status is that from experience there
> are
> many providers who never look at it, and again there's the same issue that
> they won't really be informed that we don't do predeterminations and will
> call instead. However, it's a good point to consider since our system
> will
> create entries on a database so that we can respond to a solicited claims
> status, and we will need to decide what claims status codes are most
> appropriate.
>
> Thanks for all the suggestions. It was helpful to see that people seemed
> to
> go through similar thought processes when looking at this.
>
> Jim Griffin
> Business Systems Analyst
> CNA
>
> -----Original Message-----
> From: Falbowski, Ellen [mailto:[EMAIL PROTECTED]]
> Sent: Wednesday, January 16, 2002 11:48 AM
> To: '[EMAIL PROTECTED]'
> Subject: RE: Predetermination of Dental Benefits
>
>
> Couldn't this be also handled via the unsolicited 277 claim status? The
> STC01 could carry E0 (Error in submitted request data) or A3 (Returned as
> unprocessable) in the Category Code and 187 (Date(s) of service) in the
> Status Code.
>
> -----Original Message-----
> From: Jan Root [mailto:[EMAIL PROTECTED]]
> Sent: Wednesday, January 16, 2002 2:17 PM
> To: [EMAIL PROTECTED]
> Subject: Re: Predetermination of Dental Benefits
>
>
> Jim
> You are correct that there is not a good way to do this in the 835. You
> might
> try using code '110 - Billing date predates service date' in the claim
> level
> CAS
> but I can see that it would be quite a stretch....
>
> I would suggest that you contact the Codes Maintenance Committee and
> request
> a
> new Adjustment Reason Codes. You might also want to request a new Claim
> Status
> Reason Codes if you think you might need this to respond to a claim status
> inquiry (the same committee handles both code lists). This could be a
> pre-adjudication rejection. Requests for new codes can be made at
> http://www.wpc-edi.com/conferences/crc.html. Login and go to the February
> 2002
> Issues and Agenda topic under Issues & Requests (you might have to hit the
> 'more'
> button at the bottom of the list).
>
> j
>
> "J.G." wrote:
>
> > Our plan includes both medical as well as limited dental coverage. We
> do
> > not do any predetermination of benefits today. If a provider calls in
> we
> > tell them we don't predetermine benefits. If they send in a paper form
> we
> > respond with a form letter telling them we don't predetermine benefits.
> If
> > they ask specific questions on the phone, they may get some additional
> > information, but nothing that should be close to an actual
> predetermination.
> >
> > The 837 Dental Claim transaction allows for a predetermination request.
> The
> > 835 Remittance Advice allows for a response. However, I don't see a way
> to
> > indicate that we don't perform predeterminations. Is there a way to do
> this
> > in the 835, or is there another way to respond to this?
> >
> > Jim Griffin
> > Business Systems Analyst
> > CNA
> >
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