Kepa, Thanks for this update, I think many of us will be anxious to see an FAQ or other form of clarification on this.
However, the part of your message dealing with only receiving parts of a transaction appears to be in direct conflict with the definition as currently written and some of the entity examples listed such as billing services or repricing companies. The key function of a clearinghouse is "processes or facilitates the processing of health information (not a transaction) received from another entity in a nonstandard format or containing nonstandard data content (which could be missing data elements) into standard data elements (again not a full transaction) OR a standard transaction. Regards, Leah Hole-Curry FOX Systems, Inc. 602.708.1045 Information transmitted is confidential and may be proprietary to FOX Systems, Inc. It is intended only for the person or entity to which it is addressed. Anyone else is prohibited from disclosing, copying, or disseminating the contents or attachments. If you receive this in error, please notify sender immediately, or us at www.foxsys.com and delete from your system. >>> [EMAIL PROTECTED] 06/25/02 06:37 AM >>> Colleen, Last week during the AFEHCT meeting, Stanley Nachimson of CMS clarified that a clearinghouse is one that converts an electronic HIPAA transaction from a non standard format into a standard format, or vice versa. Brilliant simple definition. Converting from a paper transaction into electronic is not a clearinghouse. Transferring electronic transactions from one point to another without converting formats is not a clearinghouse. Scanning a paper claim and converting it into electronic is not a clearinghouse. Receiving standard claims on behalf of a payer is not a clearinghouse. Receiving standard claims on behalf of a payer and converting them to non-standard for delivery to that payer is a clearinghouse. Equally interesting, receiving parts of a transaction and constructing a transaction from the parts is not a clearinghouse. A clearinghouse must receive and transmit a self-contained electronic transaction (e.g., claim) instead of parts of it. For example, an entity that has on file the provider information, the subscriber information, and gets from the providers the patient and service information from which it builds the claims in standard format is not a clearinghouse. Even if the patient and service information comes in a proprietary electronic format. The clearinghouse must receive an entire electronic transaction in proprietary format and produce an entire transaction in HIPAA standard format. Or vice versa. So, a lot of entities that thought they were clearinghouses, would fall outside of this definition. Stanley said that there will be a clarification from HHS soon on this topic. I applaud HHS for dissipating this foggy topic. Kepa On Monday 24 June 2002 12:18 pm, Grimes, Colleen wrote: > I think we need to be careful when we are interpreting other organizational > structures and I respectfully have to disagree with you. In my > orgnaization we have contracts where the clearinghouse adjudicates and pays > the claim. Some payers do not adjudicate their own claims and have > clearinghouses on their front end. In my opnion this company could be > defined as a clearinghouse and we have to be careful when we take positions > regarding stucture. If this company is scanning UB92's and HCFA 1500's to > an electronic format they are translating a paper claim into an electronic > format. Since the UB's and the HCFA 1500's do not as yet align with the > 837, it all depends what they do whit the data after it is converted. As I > said in my answer, it is wise to verify structure with both inside and > external legal counsel before decideing. > > > -----Original Message----- > > From: Rachel Foerster [SMTP:[EMAIL PROTECTED]] > > Sent: Monday, June 24, 2002 1:51 PM > > To: [EMAIL PROTECTED] > > Subject: RE: A Clearinghouse By Any Other Name ... > > > > Colleen, > > > > I respectfully disagree with your conclusion that they are solely > > performing > > a clearinghouse function. I don't believe that clearinghouses actually > > adjudicate and pay a claim. Rather, this is usually a function that is > > performed by the payer. If the payer then hires another company to perform > > that function for them, that outside company is a business associate. A > > clearinghouse under HIPAA is defined as any entity that translates > > non-standard data/format into the standard or vice versus. This company is > > scanning paper claims into a document imaging system and then keying the > > data into an adjudication system. This company's existence and role is > > totally transparent to the provider/payee. Thus, this company isn't > > translating non-standard data/format into standard, but is actually > > adjudicating the claim, and making payment based on the results of that > > adjudication. > > > > This is the rationale I used when concluding that the company is a > > business > > associate, but not necessarily a clearinghouse. I agree that a > > clearinghouse > > can play both the role of a CH and a business associate, but I don't think > > this company is doing so in this instance. Thus, my recommendation to seek > > their own legal counsel opinion. If their legal counsel concludes they are > > in effect a clearinghouse then there are much broader implications for > > them > > as a covered entity that if they are only a business associate of a > > covered > > entity. > > > > 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 > > > > > > -----Original Message----- > > From: Grimes, Colleen [mailto:[EMAIL PROTECTED]] > > Sent: Monday, June 24, 2002 11:30 AM > > To: '[EMAIL PROTECTED]' > > Subject: RE: A Clearinghouse By Any Other Name ... > > > > > > You should always check with you legal department, but what you are > > describing sounds like a clearinghouse function. A clearinghouse can be a > > buisness associate and a trading partner. > > > > Thanks, > > > > Colleen > > > > > -----Original Message----- > > > From: Rachel Foerster [SMTP:[EMAIL PROTECTED]] > > > Sent: Monday, June 24, 2002 11:44 AM > > > To: [EMAIL PROTECTED] > > > Subject: RE: A Clearinghouse By Any Other Name ... > > > > > > My opinion is that you are a business associate of the health plan, > > which > > > has outsourced this function to you to perform on their behalf. Best > > > course > > > of action is for you to confirm this with your company's legal counsel > > AND > > > the legal counsel of the health plan for which you perform these > > services. > > > > > > 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 > > > > > > > > > -----Original Message----- > > > From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] > > > Sent: Monday, June 24, 2002 9:45 AM > > > To: [EMAIL PROTECTED] > > > Subject: A Clearinghouse By Any Other Name ... > > > > > > > > > > > > > > > Would anyone here have an opinion of "what type of entity", from a > > > > > > HIPAA Transaction Rule perspective, the following operation could be > > > > > > categorized? > > > > > > > > > > > > I have an operation that receives; on behalf of a HEALTH PLAN, paper > > > claims > > > > > > from the PLAN's health care PROVIDERS (doctors, hospitals, etc.). > > > > > > > > > > > > We then take the paper claims; scan them into an imaging system, key the > > > > > > claims into our own claims processing software system (off the scanned > > > image > > > > > > of the paper claim), adjudicate the claim, cut the paper check and EOB > > > > > > and/or ERA and mail. > > > > > > > > > > > > The submitting providers; and the payee's on the backend have no > > knowledge > > > > > > of us. The checks bear the logo/address/signature of our health plan > > > > > > clients. > > > > > > > > > > > > And the address where the paper claims are mailed have the name of our > > > > > > health plan clients; with a PO Box that we set up; and from which we > > > collect > > > > > > the inbound mail. > > > > > > > > > > > > Question: does this make us a "CLEARINGHOUSE"? [I had, naively perhaps, > > > > > > assumed that a "HIPAA defined clearinghouse" was one that reformatted > > data > > > > > > from a non-HIPAA standard format to a HIPAA standard format or > > vice-versa; > > > > > > and I had assumed that the media on both sides of this are electronic - > > > but, > > > > > > when I look at the definition below; perhaps the rule applies to "paper" > > > as > > > > > > a 'non-HIPAA standard format' as well.]. > > > > > > > > > > > > > > > > > > > > > > > > Definition below for convenience - from the WEDI/SNIP Glossary > > > > > > > > > > > > Health Care Clearinghouse: Under HIPAA, this is an entity that processes > > > or > > > > > > facilitates the processing of information received from another entity > > in > > > a > > > > > > nonstandard format or containing nonstandard data content into standard > > > data > > > > > > elements or a standard transaction, or that receives a standard > > > transaction > > > > > > from another entity and processes or facilitates the processing of that > > > > > > information into nonstandard format or nonstandard data content for a > > > > > > receiving entity. Also see Part II, 45 CFR 160.103. > > > > > > > > > > > > Henry A Perretta > > > > > > HAPCO International, LLC > > > > > > 6302 Dunman Way > > > > > > Alexandria,VA, 22315 > > > > > > > > > > > > > > > ********************************************************************** > > > To be removed from this list, send a message to: > > > [EMAIL PROTECTED] > > > Please note that it may take up to 72 hours to process your request. > > > > > > ====================================================== > > > The WEDI 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. 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