At a WEDi/SNIP meeting awhile back, Stanley Nachimson gave us these guidelines on how to determine if a transaction needs to be in the HIPAA-mandated format.
1. Read the definitions of the three Covered Entities. If your organization is a covered entity, go to step 2. If you aren't a covered entity, you can stop here. 2. Read the definitions of the Transactions on pages 50370-72 of the Final Transaction Rule. If the activity you're performing meets the definition of the transaction, you need to use the HIPAA-mandated format whenever you send/receive the transaction electronically. This is a really simple roadmap that's easy to understand, and gives you an accurate answer every time. -----Original Message----- From: James Kelly [mailto:[EMAIL PROTECTED]] Sent: Thursday, May 09, 2002 11:35 AM To: Paul Weber; [EMAIL PROTECTED] Subject: Re: 834 Enrollment and Maintenance transactions Paul, Thanks for your input. I appreciate your position that X12 does not develop guides for the Federal government. I am new to this so I may be off base, but it is my understanding that the IG's were adopted as "THE STANDARD" (45 CFR 162.1502). Therefore, I would interpret anything in the guides as having the full force of law. If the guide says to not use something and I do, I am not compliant. If I use a code set that is not allowed in the guide, I am not compliant. I think the other authors of this thread and myself were hoping for a legal perspective. Are the transfers we described "covered transactions". For me it is a big difference as I write payer software. My first take on this was I had to accept an 834, not generate one. Now I am not sure. I do not want to spend limited resources implementing a transaction I am not required to use. On the other hand, if my clients do have to use this, then I better build it in. I agree in the future that we may have to back out of an 834 and use a 271 roster. But as the rules change and new transactions are covered, it is something we need to do anyway. I also would say that as we move forward we may add other non HIPAA transactions to our software to give us a competitive advantage. But for right now, I am working in a budget and need to know how to spend my resources. So if anyone from HHS is listening, I would appreciate feedback as to your interpretation. >----- Original Message ----- From: "Paul Weber" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Thursday, May 09, 2002 11:51 AM Subject: 834 Enrollment and Maintenance transactions > As one of the many volunteers who work on the 834 guide, I feel compelled to jump into this discussion. > > All of the X12N implementation guides were written as industry guides that were subsequently adopted by the secretary of HHS. It is not within our charter to develop guides for the federal government. Hence I would be reluctant to get into interpreting HIPAA regulations within our IGs. Can the definition of a payer for the 834 be revised in a future edition of the IG...sure, anything's possible. But I certainly don't want to be the one responsible for interpreting the intent of HIPAA regulations. That's what statutes and case law are for. > > The issue of the 271 vs 834 eligibility roster seems to rear its ugly head periodically. Here's my take: The purpose and scope of the 834 transaction set do not explicitly prohibit its use for an eligibility roster. However X12N has the 271 transaction set as mentioned below in this thread. The 271 work group is actively developing an implementation guide for eligibility rosters and it is my understanding that they are close to publication. > > Therefore those who adopt the 834 as an eligibility roster solution may find themselves having to go back and retrofit their systems to support the 271 transaction. Especially when smart money says the 271 roster gets named in the next round of HIPAA. > > I think what would help clarify some of this is a determination of whether the parties in question are enrolling membership in the sub-contracted plan or are verifiying eligibility for services. For instance, if claims are to be paid by the sub-contractor, then they would likely need to have enrollment (834). If the sub-contractor is capitated by the primary plan, then they likely need an eligibility roster (271) and/or interactive eligibility (270/271). > > Paul Weber > 916-449-6970 > [EMAIL PROTECTED] > > ----- Original Message ----- > From: Tucci-Kaufhold, Ruth A. > To: '[EMAIL PROTECTED]' > Sent: Wednesday, May 08, 2002 7:14 AM > Subject: RE: 834 Enrollment and Maintenance transactions > > > I also have such customers that indicated their interpretation of the situation as James stated. > > I just pointed out to the customer that the law defines them as the covered entity and they are responsible for the work that they contract out to PPOs, PBMs, etc. for specific health care transactions such as pharmacy, vision, prior auth, referrals, etc. The law is clear on that. There should be a change made to IG to relay a consistent message on the definition of health plan in an 834 and in the law. > > Now whether not they want to "interpret" it that way is a different story. So, in that case I just suggested to them that they "document" their understanding of the law, and that will explain to CMS when audit times comes around. > > Ruth Tucci-Kaufhold > UNISYS Corporation > 4050 Innslake Drive > Suite 202 > Glen Allen, VA 23060 > (804) 346-1138 > (804) 935-1647 (fax) > N246-1138 > [EMAIL PROTECTED] > -----Original Message----- > From: James Kelly [mailto:[EMAIL PROTECTED]] > Sent: Tuesday, May 07, 2002 10:32 PM > To: Stuart Thompson; [EMAIL PROTECTED] > Subject: Re: 834 Enrollment and Maintenance transactions > > > Stuart, > > I too have questions on this. I have numerous clients (Taft-Hartley union benefit plans) who contract with outside vision networks, dental and medical PPO's, and PBM's. Some of these companies are taking the position that they can still use their proprietary formats since the 834 is from an employer to a health plan. Their logic seems to be that they are not a payer since they are not ultimately responsible for the benefit payment. > > I, however, agree with your analysis. > > In regards to item 1, the 834 IG on page 8 defines a payer/insurer as: > > "The payer is the party that pays claims and/or administers the insurance coverage,benefit, or product. A payer can be an insurance company; Health Maintenance Organization (HMO); Preferred Provider Organization (PPO); a government agency, such as Medicare or Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); or another organization contracted by one of these groups." > > On item 2, I also agree. That section adopts the above quoted implementation guide as the standard. > > On item 3, I have heard of a 271 roster transaction. This transaction is used to send a list of covered members to another business associate. When a poll was done at the Wedi-Snip conference in Baltimore, most attendees indicated they were going to use the 834 for this transaction. > > I think the problem is that the definition of a payer in the IG does not match the definition of a health plan in the law. Also section 162.1501 says specifically that the 834 transaction is "to a health plan to establish or terminate insurance coverage." > > Hopefully some of the more learned members of this list will share their opinions on this. > > Jim Kelly > TPA Computer Corp > From: Stuart Thompson > To: [EMAIL PROTECTED] > Sent: Monday, May 06, 2002 7:49 PM > Subject: 834 Enrollment and Maintenance transactions > > > I would like to receive opinions regarding the following: > > Title 45, CFR �162.103 defines "Health plan" to include an individual or group plan "that provides, or pays the cost of, medical care...". "Health Plan A" is a major medical health plan that contracts Company B to provide specialized medical care (for example, vision or dental care) to Company A's enrollees. "Company B" provides that specialized medical care through its contracted providers and pays those providers = for=20 such services. To carry out its contract obligations, Company B needs to receive data identifying Health Plan A's enrollees. > > Do you agree or disagree with the following? In either case, please explain why: > > 1. Company B falls within the definition of "Health plan" because it provides or pays the cost of medical care. > 2. 45 CFR 162.1502 allows Health Plan A to send Company B the necessary data via an 834 transaction. > 3. A data transmission from Health Plan A to Company B cannot be deemed a compliant 271 eligibility response absent a 270 eligibility inquiry. > > Thank you in advance for any opinions that you would be willing to share. > > Stuart Thompson > Vision Service Plan > Rancho Cordova CA > > [*Please note: The above statements and questions are my own and do not necessarily represent the views of my employer]. > > > -- > _______________________________________________ > Sign-up for your own FREE Personalized E-mail at Mail.com > http://www.mail.com/?sr=signup >
