Jim,
You've touch on the subtle differences with
three of the Imp Guides, The X093 276/277 can be initiated by the Provider, to
inquire about the status of claim(s), The issue of a payer needing
additional information to continue the adjudication process has been addressed
in the X104, it has been awaiting an NPRM for several years now but a 4020
version is available with the 275 on WPC-EDI.COM (tagged NPRM December 2001),
The last gives a couple of choices, X070 Version 3070, can be implemented for a
Payer initiated PENDED claim listing, and the work group is finalizing the 4040
version for the Front end Acknowledgement function (837 sent by provider is
acknowledged with number of claims accepted, rejected etc.)
As for the comments regard the choice to
separate out the two business functions it was not made lightly nor in a
vacuum. The participants at the time along with input from Task Group 4
evaluated this decision. Also Jim since your a provider type entity, when
you receive a pended claim list would it provide you anymore information than if
you received a notification from the payer that the claim pended (possibly when
the claim is submitted via front end) and potentially one more time with the
request for additional information, and yet again with a timed pended claim list
if all of this were to happen within the first ten days? Remembering that
you as a provider, can also initiate the timing of the how to deal with the pend
by initiation of the 276 transaction based upon information already
received.
I hope that this thread does get too
long.
Does anyone know if the administrator of the
listserv can filter out the "Out of Office" replies to posting on this
listserv? It would reduce the email traffic and help people with cleaning
out their mailboxes.
Michael Cabral
Claim Status Co-Chair
EDS
800 Connecticut BLVD 3rd Floor
East Hartford, CT 06108
( phone: (860) 622 - 4733
fax: (860) 622 - 4774
+ mailto:[EMAIL PROTECTED]
www.eds.com
Ruth - I'd say that's a
misunderstanding... the need for the unsolicited is significant. The
ability for a payer to say "Hey - I can't continue processing until.... " or
"I'm holding up processing until..." would speed the process for ALL payers
AND providers. If using the 277 as is with small adjustments to it to
account for the lack of a paired 276, we'd all be in production quite easily,
add to that the front end accept/reject - and one transaction facilitates a
lot of this Administrative Nightmare!!
>>>
[EMAIL PROTECTED] 02/22/02 11:26AM >>>
During the
X12N conference, there was an Claims Status informational forum
held by
this X12N-TG2-WG5 to discuss the "actual" work being done in
this
workgroup. There was a misunderstanding in the industry as to
the
development of an unsolicited 277 claims status implementation
guide.
This workgroup decided that since only one portion of the
industry
(Medicaid) would be using this, that the development would be
shelved until
a better business case was presented. At that point,
myself and Kathleen
Conner from Fox systems engaged the co-chairs in
discussions that ultimately
led to the agreement that Ruth and Kathleen
would draft a white paper that
described the desired use of the 2nd half of
the 276/277 X093 transaction
for reporting pended claims and get it
approved by NMEH and then NMEH would
send it to X12N-TG2-WG5 for review and
"approval". That way a new guide
would not have to be developed (more
time wasted) and the industry has a
mandated solution. By the end of
the conference the white paper was in its
preliminary draft state to be
emailed to Kathleen Conner for review. This
white paper has been
emailed to Kathleen and Kim Meyer for review and then
subsequently to
NMEH.
If you feel that Medicaid is NOT the only part of the industry
that pends
claims, then maybe WG5's finding are not accurate. But the
solution should
still stand and just some of the front matter of the
current guide change so
that the 837 could also function as the "request"
portion for a 277 to
respond to.
Thoughts?
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: Jan Root [mailto:[EMAIL PROTECTED]]
Sent: Friday,
February 22, 2002 11:55 AM
To: [EMAIL PROTECTED]
Subject: Re:
Notifying Providers of Pended Claims
Dan
There is an 835
adjustment code for pended claims:
133 - The disposition of this
claim/service is pending further review.
Also, as a thought,
Payers
here in Utah who have this problem are considering using the 277U
for
this
business need. It's not a HIPAA transaction but it would
work fine. Plus,
they
figure since they have to implement a 277
anyway, it's not that much more
work to
implement another type of
277. And, the providers' software can handle it
with
little extra
work (since they will be handling a 277 anyway).
Jan
Root
"Clark, Dan" wrote:
> We currently notify
Providers of their pended claims on our proprietary
> electronic
remit. There is no allowance for that in the new 835. We
are
> trying to decide whether or not continue this practice and if so,
how? We
> are considering generating paper "letters" that would be
mailed to
> providers. We are also looking at creating a separate
proprietary
> electronic pend notification
transaction. And as previously stated, we
> are also
considering stopping the process of sending this information to
>
Providers.
>
> I would appreciate hearing from anyone who has a
similar dilemma and let
me
> know how you are handling
it.
>
> Thanks very much
>
> Dan Clark
>
804-678-0053
> [EMAIL PROTECTED]
<mailto:[EMAIL PROTECTED]>
>
>
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