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Rachel.
So if we get
a segment that does not related to any business of ours, such as one that
is optional, or even still, one that does not related to a waivered service
claim, we reject the whole claim even if everything required to process that
claim is accurate? Obviously we would let the provider know that segment is not
needed, does that mean bouncing the claim?
Joe
Joe,
It's your business decision whether to do this or not. You must
evaluate the risk in doing so (possible penalties, etc.) against the risk of
rejecting and then determine the business impact for either option. Make the
business decision and then act on it.
The regulation says that a covered entity must conduct a
transaction covered by the rule as a standard transaction. Non-compliant
subjects the covered entity to penalties.
Rachel
Rachel
Foerster
Principal
Rachel Foerster & Associates, Ltd.
Professionals
in EDI & Electronic Commerce
39432 North Avenue
Beach Park, IL
60099
Phone: 847-872-8070
Fax: 847-872-6860
http://www.rfa-edi.com
If a
transaction does fail HIPAA edits, but sufficient information is available to
process the transaction such as a claim, can we still process and
pay?
Given the "up in the air" aspects of HIPAA TCS error
reporting, I wonder whether or not the HIPAA transaction certification
engines that are out there today come "out of the box" configured so that they
won't "let through" a transaction if it's missing a
HIPAA-required field that is optional per X12...given the
obvious competence of the folks who are working the HIPAA effort, and the
fact that some of those folks use the WEDI SNIP testing levels 1-6 model, I'd
assume the answer is that they won't "let through" these
transactions...but we all know the dangers of assuming...perhaps
some certification engines do and some don't...
More relevant to this week's discussion is the same
question applied to transactions managers that generate 997s in response to
submitted 837s...Rachel pointed out that "... the 997
can be kludged to report guide syntax errors, such as missing
mandatory segment or element..."
(Thank you Rachel!) I wonder if the transactions
managers that are being billed as "HIPAA-ready" currently come kludged
(configured?) to do the appropriate HIPAA-specific mandatory data element
error reporting...(I'm not asking about the inter-segment dependency errors,
just the black-and-white HIPAA-mandated, X12-optional).
Sounds like there won't be a 997 or 824 IG before the
10/16/03 deadline, so what we have today is what we have...And the 997 is what
everyone is reading as the standard if they're only looking at the IGs and
addenda, which is all that they're required by law to look at...
----- Original Message -----
Sent: Friday, April 19, 2002 12:41
PM
Subject: RE: compliance with x12 vs.
HIPAA IG
When X12 says an element is optional and HIPAA says it's "Not Used",
that doesn't violate X12 because transmission of the segment without that
element is OK with X12 (because it was optional anyway). When X12 says
the element is optional and HIPAA says it's "Required", that doesn't violate
X12 either because transmission of the segment with the element always
present is OK with X12 (because optional means you can use it as often as
you like...including always). So what the HIPAA IG is doing is
creating restrictions on X12 that don't violate the original
definitions...that's pretty much how IGs are supposed to work. I think
the 997 reporting of HIPAA usage errors is still up in the air (based on the
discussion that's been going on this week).
Best regards,
Bill Chessman
Peregrine Systems, Inc.
Regarding Mike's comment below: "I would have to also
contend that the HIPAA IGs are a subset of X12. If you can't get the X12
right, you're non-compliant, right?. " My understanding is that one
CAN get the X12 right and be out of compliance from a HIPAA
perspective. Specifically, in the HIPAA Implementation Guides, the
data element attributes to the right of the data element names and
descriptions are X12; the "usage" column to the left of the de
names/descrips are HIPAA-specific. The two sometimes contradict, in
which case the "usage" column on the left takes precedence.
For example: 837P IG, p. 172 shows "Claim Filing
Indicator Code" as "O" or Optional from the X12 perspective, but NOT
USED from the HIPAA perspective. That same page shows "Health
Care Service Location Information" as Optional from the X12
perspective, but REQUIRED from the HIPAA perspective.
To summarize, my understanding is that it's the left
hand column that's the bible when it comes to USAGE
(Required/Situational/Not Used). If anyone believes that to be off
base, please advise!
Can the 997 report errors in (HIPAA-specific)
USAGE? Thanks in advance...
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