We have a
minimum of zero, and up to around 15 social service providers identified that
have the resources to partner with us with EDI. Can we come to a mutual
agreement with them via the BPA on what segments and transactions to use to
satisfy both HIPAA requirements and business needs?
Joe
Joe,
If you receive a transaction with a segment **that is
included in the HIPAA IG as either required or situational** and you don't need
the data conveyed by that segment, you are **prohibited** under the Electronic
Transaction Final Rule from rejecting the transaction on the basis that it
contains data you don't need to process the claim/transaction. Thus, if you
rejected a complying HIPAA transaction based on the fact that it contained data
allowed by the IG but data that you don't need, you would be in violation of the
regulation.
On the other hand, if you received a transaction with a
segment or element **marked not used** and you did not reject the transaction
based on non-compliance with the IG, you would also be in violation of the
regulation by conducting a non-standard transaction.
Get the difference?
In either case, you are still free to exercise a
business decision to accept the risk of violating the regulation and thereby
exposing your organization to the penalties for doing so under the regulation. I
would make my business decision only on the advice of legal
counsel.
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
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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SNIP. If you wish to receive an official opinion, post your question to the
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