Allen, The situation you describe is also part of what we face in vision. I have focused my comments on our difficulty describing eyewear products via HCPCS codes, thereby necessitating the "attachment" of proprietary "purchase orders", etc. to the claim. But payors frequently impose additional data collection requirements on the doctors that appear to have nothing to do with normal adjudication decisions (e.g., whether pupils were dilated). Whether the additional reporting is a governmental requirement, needed for adjudication, or that the plan simply considers the data "nice to have", is irrelevant to the specialized provider's problem of having to deliver it with almost every one of his/her claims. At the end of the day, the only practical way to deliver this stuff seems to be hand-keying into payors' proprietary web-forms... or via paper (commonly with "paper surcharges" of ~$3/claim) .
What seems to be missing is a standard, "reasonable man" type test that can be applied to a particular provider or provider-type, whereby we could declare with certainty that "this is the maximum data set for a standard claim in this context". For the purpose of determining whether data is part of the "claim" or something that can be "requested by other means" (even in the absence of a defined standard), it seems that we will have to consider several different care-contexts in addition to "mainstream health care claim". -Chris At 08:16 AM 1/24/02 -0800, McCall, Allen wrote: >Would your response also apply to this situation: >A government program that provides mental health care contracts with local >agencies (also government) to provide the services. The government program >is required to report the lawmakers its performance and to track services. >The program currently collects data from the local agencies that is not >included in a 837 encounter in order to meet its reporting requirements. > >Can it continue to collect the data in non-standard transactions? > >Allen > >-----Original Message----- >From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] >Sent: Tuesday, January 22, 2002 12:49 PM >To: [EMAIL PROTECTED]; [EMAIL PROTECTED]; [EMAIL PROTECTED] >Cc: [EMAIL PROTECTED]; [EMAIL PROTECTED]; [EMAIL PROTECTED]; >[EMAIL PROTECTED]; [EMAIL PROTECTED] >Subject: Re: DDE and the Use of Utilization Review Protocols for 278 >Transacti ons > > >Dear Chris: > >I do not think your question is a DDE question. It is more general. When >we >are required to use a standard transaction, we are not permitted to make it >nonstandard by requiring different or extra data. The most explicit rule on > >this is 162.915: > > "A covered entity must not enter into a trading partner agreement that >would do any of the following: (a) change the definition, data condition, >or >use of a data element or segment in a standard. (b) Add any data elements >or >segments to the maximum defined data set. (c) Use any code or data elements > >that are either marked "not used" ..., and (d) change the meaning or >intent..." > >Yet there are some interesting windows here: > >1. A payer might have to accept a standard claim but it does not have to >pay >it just because it is standard. It can ask for additional information as an > >attachment. What are the limitations on this? If a payer always requires >attachment data, is it de facto making the claim nonstandard? > >2. The explicit wording in the transaction rules is quoted above. But that > >wording speaks about a trading partner agreement. Say there is no >agreement, >written or otherwise. Say the payer says, if you want to get paid, send a >standard claim but also send us the following attachment data; else you >won't >get paid. The payer has not changed the standard technically, but in fact >it >is changing the data required on a claim. > >So I will admit to not knowing the answers here. What do you think? > >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 1/14/2002 7:59:18 AM Central Standard Time, >[EMAIL PROTECTED] writes: > > > Subj: Re: DDE and the Use of Utilization Review Protocols for 278 > > Transacti ons > > Date: 1/14/2002 7:59:18 AM Central Standard Time > > From: [EMAIL PROTECTED] (Christopher J. Feahr, OD) > > To: [EMAIL PROTECTED], [EMAIL PROTECTED], [EMAIL PROTECTED] > > CC: [EMAIL PROTECTED], [EMAIL PROTECTED], [EMAIL PROTECTED], >clstahlecker@ > > hcs-is.com, [EMAIL PROTECTED] > > > > Peter, > > I thought I understood the DDE rules, but this language conflicts >horribly > > with our present discussions in vision. "Richer data content" on the DDE > > > claim systems seems to be the most common practice in our industry. > > Frankly, it's no help to me (provider) if the payor rewrites the html >code > > so that the non-standard data is on separate screens... I still have to > > hand-type it in for 80% of my claims to get paid. The larger vision >payors > > simply declare this to be "attachment" data for which a standard has yet >to > > be created. How does this (apparently giant) attachment loophole >reconcile > > with: > > > > " A health plan may not add additional information to any of the standard > > > transactions. It may, however, provide additional information through a > > separate mechanism....The resolution of the standard transaction cannot > > depend on the additional information"?? > > > > I think we will need some clarification from HHS. I could understand a > > payor requiring "additional information" on 1 or 2% of the claims... even > >5 > > or 10%... but when they require it on 80% it smells to me like a > > proprietary claim format... end of story. > > > > Thanks for all your work on this tricky "exception", Peter. > > -Chris > > > > > > > > > > At 09:51 PM 1/13/02 -0500, [EMAIL PROTECTED] wrote: > > >Dear Joan: > > > > > >I believe that your interpretation is correct. The keys are separation >of > > >the optional data from standard and that the optional data is in fact > > totally > > >optional, not only that processing the transaction must not be dependent > > > upon > > >it, but through the no-incentive rule incentive for inclusion of >optional > > >data is not permitted. In the Impact on DDE paper we addressed this >issue > > in > > >paragraph 8.12, which I have copied below. > > > > > >Peter Barry > > > > > >8.12 Richer data content. Some existing screens may contain data >entry > > >and data response fields that are not in the standard. Continued >inclusion > > >of such fields would be non-standard except on a separate screen or, > > >presumably, a section of the screen that is clearly separate from the > > >standard. The key rule is that neither a payer or provider is permitted > >to > > >require data in addition to the standard. The HHS response was: > > > > > > "A health plan may not add additional information to any of the >standard > > >transactions. It may, however, provide additional information through a > > >separate mechanism. For example, the web-based service described in the > > >question could provide additional information on a web page separate >from > > the > > >web page containing the standard data content. The resolution of the > > standard > > >transaction cannot depend on the additional information.[c.f. Attachment > >Q4 > > >at end of this paper]" > > > > > >---------------------- > > >In a message dated 1/10/2002 6:11:16 PM Central Standard Time, > > >[EMAIL PROTECTED] writes: > > > > > > > Subj: DDE and the Use of Utilization Review Protocols for 278 >Transacti > > > > ons > > > > Date: 1/10/2002 6:11:16 PM Central Standard Time > > > > From: [EMAIL PROTECTED] (Boyle, Joan) > > > > To: [EMAIL PROTECTED] (SNIP Business Issues Listserv (E-mail)) > > > > CC: [EMAIL PROTECTED], [EMAIL PROTECTED] (Gratias, Greg) > > > > > > > > Has there been any discussion of the use of utilization review > > protocols > > > > (such as those from M&R or InterQual) in interactive DDE >applications > > for > > > > the 278? Display of these protocols in separate windows that would >pop- > > up > > > > in response to input by the provider could enhance the accuracy and > > > > usability of the data that the provider ultimately submits on the > > > completed > > > > 278 transaction. If these pop-ups are clearly separate from the > > >transaction > > > > form and their use is optional, the payer presenting the "extra" > > questions > > > > would not be actually requiring additional data for completion of >the > > > form. > > > > The submitted transaction would include only the data content of the > > > 278. > > > > > > > > Any thoughts? > > > > > > > > Joan > > > > Joan Boyle > > > > HIPAA Compliance Manager > > > > The TriZetto Group, Inc. > > > > Direct: 970-627-1675 > > > > Fax: 970-627-1677 > > > > [EMAIL PROTECTED] > > > > > > > > > >********************************************************************** > > >To be removed from this list, go to: > > >http://snip.wedi.org/unsubscribe.cfm?list=business > > >and enter your email address. > > > > Christopher J. Feahr, OD > > http://visiondatastandard.org > > [EMAIL PROTECTED] > > Cell/Pager: 707-529-2268 > > > >********************************************************************** >To be removed from this list, go to: >http://snip.wedi.org/unsubscribe.cfm?list=business >and enter your email address. > >********************************************************************** >To be removed from this list, go to: >http://snip.wedi.org/unsubscribe.cfm?list=business >and enter your email address. Christopher J. Feahr, OD http://visiondatastandard.org [EMAIL PROTECTED] Cell/Pager: 707-529-2268 ********************************************************************** 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.
