Sujay, Thanks for that link. I have discussed this issue with a Blue Plan and the definition 'not a component entity of the health plan' needs to be more clearly defined. Some payers have a CH that is a subsidiary which you would think would be a separate 'component'. Some payers have discussed selling off their CH to remove the issue completely.
Regards, David Frenkel Business Development GEFEG USA Global Leader in Ecommerce Tools www.gefeg.com 425-260-5030 -----Original Message----- From: Sujay Pidara [mailto:[EMAIL PROTECTED]] Sent: Wednesday, April 10, 2002 2:24 PM To: [EMAIL PROTECTED]; [EMAIL PROTECTED] Subject: RE: Clearinghouse question in WEDI paper I think it is answered in a way in the following Q/A on HHS. http://aspe.hhs.gov/admnsimp/q0083.htm Quoting from the answer "The definition of a health care clearinghouse in 160.103 includes the receipt and sending of transactions from and to "another entity." If the "other entity" is itself a health plan, then it cannot also be a health care clearinghouse. Therefore, if a health plan declares it is a health care clearinghouse, the health care clearinghouse would have to be outside of the health plan (i.e., not a component entity of the health plan) and there would have to be a business associate contract between the health plan and the health care clearinghouse in order that the health care clearinghouse transmits non-standard transactions to the health plan." With CH as a separate entity, it must use a standard transaction as an intermediate stage when serving both a health care provider and a health plan conducting a transaction using non-standard formats. (as stated in http://aspe.hhs.gov/admnsimp/q0101.htm ) Sujay >>> [EMAIL PROTECTED] 04/10/02 10:46AM >>> Tom, There may be an issue with Blue Cross/Blue Shield's (or other payers) that own their own clearinghouses. Can the CH in is this situation for HIPAA purposes be considered a separate entity from the payer? Could it be argued that sending a non-compliant transaction to a CH owned by a payer is still not compliant because the transaction goes from the CE directly to the payer (the CH)? Regards, David Frenkel Business Development GEFEG USA Global Leader in Ecommerce Tools www.gefeg.com 425-260-5030 -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Wednesday, April 10, 2002 6:05 AM To: [EMAIL PROTECTED] Cc: [EMAIL PROTECTED] Subject: Re: Clearinghouse question in WEDI paper Here is what is on the DHHS website for that question, dated 8/27/2001: Section 162.923(a) requires a covered entity to conduct electronic transactions with other covered entities as standard transactions, and section 162.923(c) allows a covered entity to use a business associate to conduct these transactions. Section 162.923(c)(1) requires that where a covered entity uses a business associate to conduct all or part of a transaction on its behalf, the covered entity must, as relevant here, require the business associate to comply with the applicable requirements of the transactions rule. Also, under section 162.930, a health care clearinghouse may, when acting as a business associate for another covered entity, translate a standard transaction into a non-standard transaction or vice versa. Since a clearinghouse is also a covered entity, this latter provision operates as an exception to the requirement of section 162.923(a) that covered entities conduct transactions for which standards have been adopted as standard transactions. The provider in the above scenario is using the clearinghouse as a business associate for the purpose of sending an electronic claim. The communication between the provider and the clearinghouse need not be a standard transaction. However, the covered provider must, under section 162.923(c)(1) require the clearinghouse to send the transaction as a standard transaction. Also, the clearinghouse must produce the transaction as a standard transaction for forwarding to Health Plan A, or it does not come within the exception provided for by section 162.930(b) and is consequently in violation of section 162.923(a). In the above scenario, Health Plan A is also using the same clearinghouse as a business associate for the purpose of receiving a standard electronic claim. Health Plan A may contract with the clearinghouse to translate, on Health Plan A's behalf, a standard transaction to Health Plan A's non-standard format and, under section 162.930(a), the clearinghouse may do this on the health plan's behalf. The communication from the clearinghouse to Health Plan A need not be done as a standard transaction, because the communication comes within the exception provided for by section 162.930(a). Thus, the clearinghouse may translate the standard transaction into a non-standard transaction and forward it to Health Plan A. The inescapable result of this logic is that a clearinghouse must use a standard transaction as an intermediate stage (even if only for a microsecond) when it serves both a health care provider and a health plan conducting a transaction using non-standard formats. Here is the link ==> http://aspe.hhs.gov/admnsimp/q0101.htm ____________________________________________________ Tom Ihlenfeldt Metropolitan Health Plan Minneapolis, Minnesota 612/347-3497 Sherri Gerhardt <Sherri.Gerhardt@P To: "'[EMAIL PROTECTED]'" REMERA.com> <[EMAIL PROTECTED]> cc: 04/09/2002 02:24 Subject: Clearinghouse question in WEDI paper PM Please respond to transactions The following reference was made in the WEDI SNIP paper titled Clearinghouse Transactions and Connectivity, Page 16. Does anyone know if there has been any response from HHS and what that response was? Thank you! [The SNIP Business Issues sub-group is submitting this point for a formal and final response as a question to HHS as follows: If a clearinghouse is under contract to both a provider and a health plan, and currently receives transactions from the provider in its proprietary format and translates them to the plan's proprietary format, do the HIPAA regulations require that this process change? Would the clearinghouse be required under the regulations to convert non-standard provider transactions to standard format before then changing them to the plan's proprietary format, adding a seemingly unnecessary step to the current process?] ********************************************************************** 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. ====================================================== The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited. ********************************************************************** 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. ====================================================== The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. 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Posting of advertisements or other commercial use of this listserv is specifically prohibited. ********************************************************************** 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. ================== The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited. ********************************************************************** 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. ====================================================== The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited.
