A way to answer your question is to look at the specific language of the final electronic transaction rule which defines a claim transation thusly:
� 162.1101 Health care claims or equivalent encounter information transaction. The health care claims or equivalent encounter information transaction is the transmission of either of the following: (a) A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care. (b) If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care. Since you are neither requesting payment or providing encounter information, it is my opinion that the transaction you send to your repricer is not a claim as defined by HIPAA and therefore, you are not required to conform to either the format or data content. 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: Friday, October 11, 2002 3:19 AM To: [EMAIL PROTECTED] Cc: [EMAIL PROTECTED] Subject: 837 Claims Received by Health Plan - Forwarded to Repricer Has anyone run into this situation and/or have an opinion on the following question? I am a Health Plan under HIPAA (using a little euphemism here). I "rent" a provider network to complement my own PPO (for member coverage outside my service area). All claims are sent to me (the Plan) today - both electronic and paper. During the adjudication process - I determine if a claim needs to be repriced by my rented network vendor. At that point, I suspend processing of those claims - forward them on to my repricer - who reprices them and sends them back to me - and I continue processing. QUESTION: after 10/16/2003 - does HIPAA mandate that the "claim" I send to my repricer be in the 837 format? I suspect the answer is NO - but wonder what you think. The scenario is (again): HIPAA CLAIM FROM PROVIDER - to HEALTH PLAN - to REPRICER - to HEALTH PLAN. And the question is: From HEALTH PLAN to REPRICER - does HIPAA mandate that be a HIPAA 837? ********************************************************************** 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.
