Hi: Good question! There are no easy answers.
So long as you convert electronic transactions from standard to non-standard format or vice-versa, you organization will be treated as a Clearinghouse and therefore will be a "Covered Entity". It does not matter whether any other Clearinghouse is involved in the process or who pays for the services. I don't think, your Health Plan's clearinghouse cannot transmit 837 in a non-standard format if it receives the claims in the non-standard format from the providers. This would be against the definition of Clearinghouse under HIPAA. On the other hand, a Clearinghouse received data from an entity, converts it from one format to another (standard to non-standard or vice-versa) and then TRANSMITS the data to another Receiving entity. This suggests that Clearinghouse acts only as a value-added post-office and must transmit the data from one entity to another. In your case, the transaction received is processed but NOT TRANSMITTED to another entity, at least as the same transaction. You may though send a remittance advice transaction (akin 835) after processing the claim (akin 837), which is a different transaction. Going by this argument, your organization should not be treated as a Clearinghouse. Of the two arguments, I would go with the second one. I think, your organization is more like a "Business Associate" rather than a "Clearinghouse" as you are not transmitting the same transaction to another entity. Regards, Raj ***************************** Rajesh (Raj) Agarwal Practice Manager Concio Corporation 3130 Coronado Dr Santa Clara, CA 95054 Dir: (408) 562 6610 www.concio.com ***************************** -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Monday, July 15, 2002 2:51 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? ********************************************************************** 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. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited. ********************************************************************** 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. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited.
