Chris, could you please elaborate on what is meant by "to support a capitated payment plan". We are just starting to look into HIPAA for our capitated payments ( HMO, Global cap etc ) and our understanding is that we need to use the 835 for the capitation payments ( not the 837 , see section 2.2.10 on the 835 ). Included in the 835 cap payment are any deductions entered on the system whether manual deductions ( user entered and may be positive or negative ) and deductible referrals which are generated automatically from our claims system. When we put these on the 835 ( or is it the 837 ? ) for the payee under the capitated plan, do we put one summary entry or each individual one? For example, if the payee has say 100 different deductible referrals for the same provider that total to say $10,000 can we include one summary amount or do we need to list all of the individual amounts? In regards to the encounters, since they represent no money changing hands on the claim, why would we need to include them with a capitation pavement? Or is that referring to the Disbursement's side where the risk tables say do not pay the claim since it is encountered? Thanks any help is appreciated
Harvey Alan Splaver Finance IS Antares Management Solutions 216-292-0400 ext.3333 [EMAIL PROTECTED] >>> [EMAIL PROTECTED] 07/18/02 03:30PM >>> Kris, Your statement is surprising to me (of course, a lot of things are... and that certainly doesn't make them incorrect!). But are you saying that the 837 is NOT the definitive, HIPAA-standard for reporting of "encounter data"? If the encounter data is sent to support a "capitated" payment plan, I believe that the 837 is absolutely required. But are you saying that "data to support risk adjustment" can be sent in any mutually agreeable format? This seems to suggest that the payor's intended use of the "claim or encounter" data will determine whether or not to use the 837 to send it... is this what you are saying? I'm still not sure I see how this would let the Medicaids off the hook or make the 837 optional in some way. Doesn't all this "risk adjustment data" eventually impact payments to providers? Thanks, Chris At 11:41 AM 7/17/2002 -0600, Owens, Kris wrote: >Encounters to whom? The regs do list it as the format for both claims and >encounter data. > >- For encounter data from a provider to a payer we say yes. >- If you are an MCO working with Medicare (an M+ Choice plan) the answer >is no. CMS is now requiring "data to support risk adjustment" and are >asking for about 6 fields of data. They will accept the 837 if you want >to send it or your current NSF format or their new format. > >- If you are reporting encounter data to a Medicaid agency the answer is >maybe, ask their fiscal intermediary. About 1/2 the state Medicaid >programs are asking for the 837 and about 1/2 are not. > >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: Goldman, Shellie >[<mailto:[EMAIL PROTECTED]>mailto:[EMAIL PROTECTED]] >Sent: Wednesday, July 17, 2002 11:10 AM >To: '[EMAIL PROTECTED]' >Subject: Encounter Data > >Is the 837 transaction set required for encounter data? I cannot find >anywhere in the regs that indicate it is not. If you have the site in the >regs, please let me know. > > > > > >********************************************************************** >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. 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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. > > > >--- PRESBYTERIAN HEALTHCARE SERVICES DISCLAIMER --- > >This message originates from Presbyterian Healthcare Services or one of >its affiliated organizations. It contains information, which may be >confidential or privileged, and is intended only for the individual or >entity named above. It is prohibited for anyone else to disclose, copy, >distribute or use the contents of this message. All personal messages >express views solely of the sender, which are not to be attributed to >Presbyterian Healthcare Services or any of its affiliated organizations, >and may not be distributed without this disclaimer. If you received this >message in error, please notify us immediately at [EMAIL PROTECTED] Christopher J. 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