>From my experience, a clean claim generally means that the claim has all the >necessary information to process/adjudicate the claim and a determination >(paid/denied) can be made on the claim.
If I recall correctly, there is some regulation(s) (either specific to states or to Medicare, etc) that requires payers to report as how many clean claims were processed to the final status (paid/denied) in what time period or mandates that a determination should be made on high percentage (90s) of clean claims within a specific timeframe. The determination could be denied or paid but the denial reason couldn't be incomplete claim. The claim cannot be pended/hold/suspended. However, the payment doesn't have to be the same as the charged amount on the claim. Maybe the intent of the AHA letter is that a HIPAA compliant claim should be termed as a clean claim thus requiring payers to make a determination in a specific timeframe. Just my opinion, Sujay Pidara Radicle Incorporated 773-991-6018 >>> David Kibbe <[EMAIL PROTECTED]> 05/06/02 09:18AM >>> Let me chime in here, too, from the physicians' office perspective. Medical practices and physician membership organizations are beginning to realize that there may be large up front costs associated with HIPAA TCS compliance. It does not help that these costs are hard to predict, and loom as unbudgeted items for fiscal years 2002-2004. The majority of hospitals, particularly smaller community institutions, share with medical practices the added vulnerability and uncertainty of having to rely on vendors and clearinghouses, and to some extent payers, to bring them solutions. However, these entities are far from forthcoming about either the solutions themselves, or the added costs they may involve. This is in part, I believe, because they themselves don't know the answers. Some are in frank denial. Some are telling their clients "Don't worry, we're HIPAA compliant." By now, many medical practices and hospitals know this is not going to be satisfactory as an answer, and the angst is mounting the closer we approach October, 2003. I would interpret formal calls from provider organizations for increased movement on HIPAA TCS in this light. DCK David C. Kibbe, MD Director, Health Information Technologies American Academy of Family Physicians Leawood, Kansas Founder and chair Canopy Systems, Inc. Chapel Hill, North Carolina tel: 800-757-1354 email: [EMAIL PROTECTED] or [EMAIL PROTECTED] -----Original Message----- From: Mimi Hart [mailto:[EMAIL PROTECTED]] Sent: Monday, May 06, 2002 10:05 AM To: [EMAIL PROTECTED]; [EMAIL PROTECTED]; [EMAIL PROTECTED] Subject: RE: FW: Article My "personal" two cents worth...I am also disappointed in some of the comments that have been made since David forwarded the article... I don't believe that AHA is advocating the payment of fraudulant claims, or even "non-claims" ...I believe they were giving voice to the frustrations of providers who have been told time and time again that HIPAA is going to give us an ROI because of "standardization of transactions"...but instead we are faced with ambigous details that seem to undermine the original purpose of administrative simplification......allow us to send standard transactions with as little paper work and human intervention as possible, therebye reducing the cost to consumers...an ROI for everyone...(as we all pay insurance premiums)....MIMI Mimi Hart Research Analyst, HIPAA Iowa Health System 319-369-7767 (phone) 319-369-8365 (fax) 319-490-0637 (pager) [EMAIL PROTECTED] >>> "Fody, Kenneth W." <[EMAIL PROTECTED]> 05/03/02 03:50PM >>> Actually, I'd be curious to know what AHA means by their request. On the one hand, it seems redundant, because HIPAA clearly requires Payers to accept standard transactions. On the other hand, AHA may be suggesting that payers not be permitted to request additional information -- however an 837 does not provide all the information necessary to process a claim. It seems to me that HHS and HIPAA recognize this because a claim attachment transaction is being developed. Finally, AHA says they are unhappy because payers don't process claims fast enough. However, HIPAA has nothing to do with what a payer does with a claim once it receives it, except that a payer can't process an 837 slower than it processes other claims. So the comments are either naive in not recognizing the fact that HIPAA requires payers to accept standard transactions, or the comments are ominous in that AHA is going to try to take HIPAA in directions it was not meant to go. I guess I'm also a little disappointed by these kinds of statements too. They seem to further the atmosphere suspicion, animosity, and gamesmanship where one side tries to "beat" the other side, that currently exists on both sides. What is really needed is to promote a positive, collaborative, "we're all in this together so lets make the best of it" atmosphere that we really need to achieve if all of the covered entities are to successfully work together to make HIPAA work. Ken Fody Independence Blue Cross -----Original Message----- From: David Frenkel [mailto:[EMAIL PROTECTED]] Sent: Friday, May 03, 2002 3:43 PM To: [EMAIL PROTECTED]; 'WEDi/SNIP ID & Routing' Subject: RE: FW: Article This is an interesting article from yesterday's AHA news. Regards, David Frenkel Business Development GEFEG USA Global Leader in Ecommerce Tools www.gefeg.com 425-260-5030 AHA urges HHS to require health plans to accept HIPAA claims AHA in a letter today urged HHS Secretary Tommy Thompson to adopt a rule or guidance requiring health plans to accept hospitals' claims compliant with the Health Insurance Portability and Accountability Act. According to the letter, one of the major administrative costs and sources of frustration facing hospitals is frequent claim payment delays, particularly by private payers. The final HIPAA regulation on electronic formats and code sets established national standards for electronic submission of claims, and makes clear that health plans are not permitted to require additional elements that deviate from those specified, the letter adds. Plans can be somewhat arbitrary in processing, leaving providers facing payment delays and engaged in "wasteful" resubmissions and reconciliation. The letter asks HHS to clarify that plans must accept HIPAA-compliant claims for contractual provisions with other entities covered under HIPAA and for state and federal prompt pay requirements. The letter will be at <s....allow us to send standard transacthttp://www.aha.org>. CONFIDENTIALITY NOTICE: This E-Mail is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you have received this communication in error, please do not distribute and delete the original message. Please notify the sender by E-Mail at the address shown. Thank you for your compliance.
