A word of caution, determining what type of entity you are is a complicated process. I would suggest that instead of asking opinion of the listserv community, you talk with legal council, work with them to make that determination and document it. Determining what type of entity you are is based on what you are doing and for whom and under what sorts of agreements. You really have to dig through the detail. It is not a straight forward (at least in our experience) decision. This decision will drive your approach to your compliance, and personally, I wouldn't trust it to the opinion of the listserv community (despite the vast amount of knowledge the listserv represents) because a listserv by definition is just that - opinion. I believe you need legal determination for this question.
Kris Owens
Senior IS Project Manager - HIPAA Project
Presbyterian Healthcare Services
Albuquerque, NM
505.923.8108
[EMAIL PROTECTED]
"Complex systems evolve from simple rules"
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Monday, July 15, 2002 3:51 PM
To: [EMAIL PROTECTED]
Subject: Return of the Mystery Clearinghous
A few weeks ago, I (essentially) asked the question: "if a Business Associate
accepts paper claims from its Plan-client's providers (on behalf of the
Plan-client); then scans and (essentially) creates electronic data (OCR data)
from that paper - for subsequent claim adjudication & payment - does that make
it a HIPAA Clearinghouse"?
The resulting discussion was very enlightening - but the overall verdict was
NO: although the Rule is a tad ambiguous in this area; the overwhelming
presumption is that a Clearinghouse must be working with electronic data on
BOTH the INPUT and OUTPUT side to BE a HIPAA Clearinghouse.
The above seems to be supported in several papers (including a SNIP white
paper) and CMS as well.
SECOND QUESTION (a bit trickier):
Again, I'm a Business Associate of a HIPAA Plan (several, actually).
Today, for one client; I actually log on to a commercial clearinghouse (the
biggest one; name begins with a "W") - and I FTP down every day a claims file.
These claims are, again, filed by my Plan-client's providers.
My Plan-client pays "W" for clearinghouse fees (subscription fee, transaction
fees, etc.).
I take this claims file; and use my own EDI translator to load into claims
payment software that I operate on behalf of my Plan-client.
I pay the claims (both paper and electronically submitted) for my Plan-client.
[I'm not at medical dollar risk - this is admin services only].
Here's the question: Am I, in the above capacity, operating as a HIPAA
Clearinghouse? (at least on 10/2003; with extension).
ARGUMENT FOR: Well, I AM accepting claims electronically; and I am
reformatting them.
ARGUMENT AGAINST: Well, the PLAN is paying the Clearinghouse; so the PLAN can
insist that the Clearinghouse send claims in a format other than the HIPAA 837
to me (on their behalf). In this sense, I'm just; well ... a Business
Associate of the PLAN; representing it's operations. In this sense, there is
no difference than if the Clearinghouse were to send these claims DIRECTLY to
the PLAN.
What do you think?
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