I will be grateful to anyone who provides citations to regulations, comments
on regulations, HHS FAQs, e-mails by HHS representatives, or any other
reasonably authoritative sources not referenced below, that contradict (or
support) the following position:
A Medicaid agency's pre-HIPAA electronic remittance advice (proprietary RA)
includes typical RA data elements for the adjudicated claims, plus
additional information about pended, suspended and denied claims, including
explanations and resolution aids. This "nice-to-have" additional
information is much appreciated by its providers, who will be dismayed if it
becomes unavailable. Until the HIPAA drop-dead date next year, the agency
will continue to transmit the proprietary RA on tape, even to providers with
whom it has begun to exchange standard transactions. That is, submitters of
837s would receive both 835s and proprietary RAs. The question is whether
the agency can continue to do so for some indefinite period after October
2003, until the 835 or some other transaction is modified to accomplish the
same purpose.
I am unaware of any way, consistent with �162.915, that the agency can
include pended and suspended claims information in the 835. However, I
believe that so long as the agency transmits compliant 835s to providers, it
can continue to send the proprietary RAs after October 2003 without being
non-compliant.
My colleagues are less confident in that conclusion than I am.
Some have suggested that we could provide the proprietary RA on paper, but
not electronically. This appears to be based on the response to comment
numbered (xiv) in FR Vol. 65, No. 160/ Thursday, August 17, 2000/Rules and
Regulations, p.50335, which said, in part:
A health plan can choose to continue to send paper remittance
advice notices to health care providers that are issued
ASC X12N 835 transactions. However, all information in the
paper notice that could have been expressed in the X12N 835
must be included in the X12N 835 transaction.
Since the question to which the comment responded asked about a paper RA,
the fact that a paper RA was declared acceptable does not compel the
inference that forms other than paper are unacceptable.
�162.923(a) requires that an electronic transaction between covered entities
for which a standard has been adopted must be conducted as a standard
transaction. That does not appear to prohibit the practice described above,
where standard transaction are conducted, but the agency gives the provider
something more.
Another FAQ said "health plans may continue to accept additional electronic
formats after the ... compliance date only if the submitter is not a covered
entity...." That also appears not to prohibit the practice described above,
since it is providers, not the health plan, who will be accepting additional
electronic formats.
The following FAQ and answer describes a situation very close to ours, and
appears to support the practice that my agency wants to continue:
Q: If a covered entity adheres to the data content requirement,
can they also provide additional information using other
technologies? For example, if a health plan has a Web query
solution for claim status, and meets all data content requirements
for the 276 request and the 277 response, could they also provide
additional information regarding the status of the claim? An
example of additional information would be to provide claim
resolution instructions for denied claim, or a statement that
would better clarify the action taken on the claim.
A: A health plan may not add additional information to any of
the standard transactions. It may, however, provide additional
information through a separate mechanism. For example, the web-
based service described in the question could provide additional
information on a web page separate from the web page containing
the standard data content. The resolution of the standard
transaction cannot depend on the additional information.
The expressions "other technologies" and "separate mechanism" are somewhat
ambiguous, but the example apparently assumes that the additional
information can even be transmitted in the same medium as the standard
transaction, so long as the standard transaction itself is complete,
unaltered and separate.
Finally, �162.925(4) says a health plan may not offer an incentive for a
provider to conduct a transaction as a transaction described under the
exception for the direct data entry (DDE) allowed by 162.923(b). Our
response to a DDE will be the proprietary RA, unless the provider requests
an 835. But if we are prohibited from providing the proprietary RA in
addition to the 835, then NOT sending both to 837 submitters could be seen
as offering an incentive to use DDE.
I conclude that my agency would not violate the transaction rules by
continuing to send the proprietary RA after the compliance deadline IN
ADDITION TO AND SEPARATE FROM the 835. And it is not necessary to strip
from the proprietary RA data that is redundant to the 835.
Can anyone cite any contrary opinion expressed by HHS in any forum?
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