Privacy and security rules will most likely be warranted also. Joe -----Original Message----- From: Rachel Foerster [mailto:[EMAIL PROTECTED]] Sent: Tuesday, July 16, 2002 10:12 AM To: [EMAIL PROTECTED] Subject: RE: Return of the Mystery Clearinghouse
I think the key is that at some point the claim from the provider MUST be in the standard format. In the scenario you described I could envision that taking place in a couple of ways: 1. The provider sends the claim to the big W clearinghouse in the standard format; the clearinghouse reformats the standard claim into a non-standard format before you FTP the file. In this case, the clearinghouse is a business associate of the payer/health plan. 2. The provider sends the claim to the big W clearinghouse in a proprietary format and the clearinghouse reformats it into the standard format before you FTP the file. In this case the clearinghouse is a business associate of the provider. In any case, the claim must, even for a nanosecond, be put into the standard claim transaction format at some point on its journey to your system, which is actually a surrogate of the health plan/payer. Rachel 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, July 15, 2002 4:51 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. ********************************************************************** 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.
