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Joe,
As long as the segments in question are part of the
current HIPAA IG for the specific transaction, you can reach agreement via a
TPA, as long as the TPA does not in any way change the usage, definition,
format, etc. of the segments and elements in question. You cannot via a TPA or
otherwise, require a provider to send you data that is marked as *not used*
in the HIPAA guide. These TPA may be accompanied by what's nominally
characterized as "companion documents."
You may also in a TPA indicate what transactions are
needed for the business, and as a matter of fact, you could even reach agreement
on the use of non-HIPAA transactions. HIPAA doesn't prevent trading partners to
agree to use other transactions to support a given business
process.
However, as a payer, you are required under HIPAA to be
able to conduct **all** of the specified HIPAA transactions in compliance with
the rule and specifications.
Rachel
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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WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official
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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
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