Here is how we have interpreted the transmissions between
providers/networks/clearinghouses/payers.
Option 1
Provider submits to clearinghouse either in paper or electronic format
(PMS)
� Does not have to be compliant.
Clearinghouse sends to Payer
� Must be compliant
Option 2
Provider submits to PPO network in paper or electronic format
� Does not have to be compliant
Network reprices and sends to clearinghouse
� Does not have to be compliant
Clearinghouse sends to Payer
� Must be compliant
Option 3
Provider submits to network in paper or electronic format
� Does not have to be compliant
Network sends to Payer
� Must be compliant
Option 4
Provider submits to clearinghouse in paper or electronic format
� Does not have to be compliant
Clearinghouse submits to another clearinghouse or network
� Does not have to be compliant
Clearinghouse or Network submits to another clearinghouse or network
� Does not have to be compliant
Clearinghouse or Network submits to Payer
� Must be compliant
Option 5
Provider submits directly to Payer in paper format
� Does not have to be compliant
Option 6
Provider submits directly to Payer electronically
� Must be compliant.
Stacey Denil
HIPAA Project Manager
American Medical Security
1-800-232-5432 ext 14566
[EMAIL PROTECTED]
"Heiert,
David" To: "'[EMAIL PROTECTED]'"
<DHeiert@accu- <[EMAIL PROTECTED]>
med.com> cc:
Subject: RE: Must providers/billers
comply
02/18/2002 with all formats
11:41 AM
Please respond
to
transactions
Is that true? Providers can send non-compliant electronic data to
a clearinghouse?? Not according to what I understand.. Which
could be way off....
Now, they could send you paper (or a fax) and you could convert that
to HIPAA transactions for them... I think that would be OK...
-----Original Message-----
From: Claudia J. Egan [mailto:[EMAIL PROTECTED]]
Sent: Monday, February 18, 2002 12:36 PM
To: '[EMAIL PROTECTED]'
Subject: RE: Must providers/billers comply with all formats
Why not contract with the providers to be their clearinghouse? If you take
on the burden of providing compliant transactions to their payors, the
providers can send you whatever non-compliant transactions they wish.
Of course, the burden of converting all the transactions may be too large
($$) . . . .
Claudia Egan
-----Original Message-----
From: Heiert, David [mailto:[EMAIL PROTECTED]]
Sent: Monday, February 18, 2002 11:21 AM
To: '[EMAIL PROTECTED]'
Subject: RE: Must providers/billers comply with all formats
I don't think any of the legacy electronic formats will be allowed...
I guess in your situation, the providers with have to send you either
paper or HIPAA compliant electronic files... I don't see any other
alternative...
You are right, you can't force the providers to send electronic data,
BUT if they do it must be HIPAA compliant... That is how I understand it,
anyway....
-----Original Message-----
From: Tracy A. Mitchell [mailto:[EMAIL PROTECTED]]
Sent: Monday, February 18, 2002 12:09 PM
To: [EMAIL PROTECTED]
Subject: RE: Must providers/billers comply with all formats
Wes,
You have not understood what I wrote. As I am sure you know, some
providers still have their spouse hand write the claim and mail it in;
they certainly don't have EDI capability. Some of the ones that do send
in NSF formats WILL fall back to paper because they will not make the
investment in the systems necessary for HIPAA transactions. To think
otherwise is to not understand the feelings of providers that feel
squeezed from all sides, that feel they are surrounded by people with
their hand out and that hate managed care anyway. I'm not saying that I
agree with the sentiments. But anyone that has worked in provider
relations knows the sentiment is there. I was hoping that I could
continue to RECEIVE the NSF files from those providers that send them.
That is why I asked the question in the first place. There seems to be
disagreement on whether or not it is allowable for me to do so.
My company WILL convert these claims to HIPAA formatted outbound
transactions for any payer that wishes to receive them. When we send EDI
files currently, we send only ANSI outbound transaction (3041 for some
and 4010 for those that can receive them). But we can not force the
providers in our network to send in HIPAA transactions. Yes in the long
run there will be a nice flow of EDI claims but in the short run my
inbound EDI volume will likely drop and my outbound volume will
increase.
Mr. Tracy A. Mitchell
Director Information Services
Arizona Foundation for Medical Care
-----Original Message-----
From: Rishel,Wes [mailto:[EMAIL PROTECTED]]
Sent: Saturday, February 16, 2002 11:23 AM
To: [EMAIL PROTECTED]
Subject: RE: Must providers/billers comply with all formats
Tracey,
You seem to believe that you will be forced go back to paper if you are
ready on the new format and the payer is still on the old format. That
is
not an inescapable conclusion. One would hope that your approach to
HIPAA
would allow you to selectively use an old format or the new format on a
per
health plan basis. This should not be too much of a challenge since you
currently are required to use different formats for different health
plans.
Your job is to use that capability to switch to the new format for each
health plan.
It has never been remotely possible that all health plans would switch
to
the new formats at exactly the same time, so this has always been a
requirement. The extension just prolongs the time frame where you must
continue to support multiple formats.
Wes Rishel
Board Chair, Health Level 7
Vice President, Research Director
Gartner Research, Healthcare
Alameda, CA
510 522 8135
[EMAIL PROTECTED]
See us at the Gartner Healthcare Business and IT Summit
15-17 April 2002
Sheraton Boston Hotel
Boston, MA
http://www3.gartner.com/2_events/conferences/hit4/hit4.jsp
-----Original Message-----
From: Tracy A. Mitchell [mailto:[EMAIL PROTECTED]]
Sent: Friday, February 15, 2002 2:10 PM
To: [EMAIL PROTECTED]
Subject: RE: Must providers/billers comply with all formats
Darn, I was afraid of that. We are a not-for-profit repricing PPO. Our
board of trustees is made up of MDs and DOs. I love EDI files and my
company will be HIPAA ready this year, but many, many providers have old
systems that they will not upgrade by Oct 2003. So, I suspect my
inbound EDI volume will drop and my data entry cost will go up over the
next few years. I was hoping that I could a least keep the ones that
could send NSF formats. I would support both.
Oh well, at least the payers are suddenly returning my phone calls
regarding EDI.
Mr. Tracy A. Mitchell
Director Information Services
Arizona Foundation for Medical Care
-----Original Message-----
From: Sayman,William [mailto:[EMAIL PROTECTED]]
Sent: Friday, February 15, 2002 1:31 PM
To: '[EMAIL PROTECTED]'
Subject: RE: Must providers/billers comply with all formats
Covered entities are required to use standard transactions.
� 162.923 Requirements for covered entities.
(a) General rule. Except as otherwise provided in this part, if a
covered
entity conducts with another covered entity (or within the same covered
entity), using electronic media, a transaction for which the Secretary
has
adopted a standard under this part, the covered entity must conduct the
transaction as a standard transaction.
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