I don't know that the question should be "How are health plans accommodating the required 837 Professional elements that can not be obtained from a paper claim?", but rather "What are providers, their vendors and their clearinghouses doing to fill the gap between data available today and that required under HIPAA?". The requirements for compliance are defined by HIPAA's implementation guide, not by the payer. A payer could tell a provider that they do not require any of the data you mention below (and many will) but that does not mean the provider is compliant. Also, the issue may not just be format. A data gap can exists not only in the HCFA but also the NSF and even in an 837 since the data must be collected and stored in a system in order to be populated in a claim. In some cases, even though an 837 claim format can be produced, the required data elements don't exist.
Clearinghouses and payers are working closely to try and find a work around to the kinds of elements you have mentioned here. Some of those solutions will result in a fully compliant claim and some will not. In some cases it would appear the payers and clearinghouses have weighed the cost of compliance and decided the cost to comply outweighs the risk of non-compliance. The question providers should be asking themselves is whether or not they agree and want to take on that risk. Providers should not simply hand over their compliance to a clearinghouse or payer. They should take an active role in determining what compliance will mean for them and what risks they are willing to take. One comment on the data you mention below, the HCFA 1500 allows either an LMP or a date of illness. A single field is used for this information and no indicator exists to differentiate one type of date from another so unless a clearinghouse can find another way to determine which is which, it may not map the date correctly. Also, what about the pregnant women who is diagnosed with gestational diabetes? In that case both an LMP and a date of illness is required and cannot be accommodated on a HCFA. No simple answers. Providers need to do their own gap analysis and, working with their clearinghouse, vendors and payers, come up with solutions they are comfortable with. They should not allow another entity to determine the acceptable level of risk. Some clearinghouses are offering gap analysis services where they compare the actual claim data sent today with the data required in the same claim post HIPAA. This would save the provider a lot of time and allow it to look at only the data gaps that impact its claims. Providers should be asking their clearinghouse how it plans to assist with this. Don't know if that helps but I hope in generates more discussion. Marcallee Jackson Long Beach, CA 562-438-6613 -----Original Message----- From: Art Schenkman [mailto:[EMAIL PROTECTED]] Sent: Friday, October 11, 2002 1:49 PM To: '[EMAIL PROTECTED]' Cc: Anne Romer Subject: Missing Elements on an HCFA 1500 How are health plans accommodating the required 837 Professional elements that can not be obtained from a paper claim? ambulance services, spinal manipulation, pregnancy For example, If a chiropractor does a spinal manipulation, we would expect him to submit his bill on a HCFA 1500 claim form For spinal manipulation, there are several required fields within the 837. Within the 2300 loop CR2 detail (Spinal Manipulation Service Information), the following information is required and can not be found on a paper claim: Treatment Series Number, Treatment Count, Subluxation Level Code, Treatment Period Count Monthly Treatment Count, Patient Condition Code, Complication Indicator For ambulance transports, loop 2300 detail CR1 (Ambulance Certification), required and not on a paper claim Ambulance Transport Code, Ambulance Transport Reason Code. For obstetrical claims, the paper claim provides the last menstrual cycle date but not the estimated date of birth. We are required to include this information when we submit the 837 to our state agency. Has anyone addressed and or resolved an issue similar to this? NOTE: This is a re-send of two earlier emails that have experienced receipt problems. This message is in PLAIN TEXT FORMAT ********************************************************************** 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.
