This note of mine arrived to the list serve out of sequence. I hope it didn't confuse the discussion. I have been getting some great information here in the last couple of days. Thanks to all.
Catherine Lohmeier -----Original Message----- From: Catherine Lohmeier (Consultant) [mailto:[EMAIL PROTECTED]] Sent: Tuesday, October 15, 2002 10:45 AM To: '[EMAIL PROTECTED]' Subject: RE: Missing Elements on an HCFA 1500 The average provider does not have the staff or technical expertise to go through each of the implementation guides for each transaction. What does WEDI recommend as a publicly available preliminary analysis that would help them jump start this process??? Is there such a thing?? Should providers just bite the bullet and hire someone to do this for them. Is this something the Practice Management Software vendor should be doing side by side with the provider's office manager or whoever was appointed to be in charge of this? Is this outlined in the WEDI white paper for small provider implementation? We are rapidly getting to the point where philosophical discussions of what should be done must be replaced by practical "how to" suggestions and best practices. -----Original Message----- From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]] Sent: Monday, October 14, 2002 10:41 PM To: [EMAIL PROTECTED]; Marcallee Jackson Cc: 'Anne Romer' Subject: Re: Missing Elements on an HCFA 1500 This is one of the reasons why it is not enough for a provider to upgrade to a software version that is "HIPAA compliant", or to use a clearinghouse that is compliant. Unless the provider in question implements remediations steps that include capturing the necessary data, that provider will still not be compliant even if they are using the latest software or clearinghouse. Remember, HIPAA EDI is not just about EDI format but mostly about the data content in those EDI transactions. And the paper 1500 or UB92 claims do not have everything that the EDI transactions need. Kepa On Monday 14 October 2002 10:53 am, Marcallee Jackson wrote: > Anthony- > > I think the point of HIPAA is to move everyone to electronic > transactions using the HIPAA 837. That's the "give". Providers are > expected to remediate systems and processes in order to collect the > required data and produce a fully compliant electronic claim file. The > intention is to move away from paper claims and to electronic claims. > If providers are sending paper claims, the standard does not apply so > the data elements that are a challenge in the 837 do not need to exist > on the paper 1500. If you send electronic claims, you include all data. > If you send paper, you send only the data required on the HCFA/CMS 1500 > form. Presumably since the data does not exist on a paper claim today, > it is not actually required for adjudication. The requirements of the > 837 were not developed with translation from a 1500 to the 837 in mind. > > > That's the rub. The data you mention is likely not required for claims > payment. Just for HIPAA compliance. Which goes back to my statement > that it is the provider who needs to decide the extent to which they > wish to be compliant and the acceptable level of risk. A payer could > tell you that they do not require this data for adjudication and that > they would accept an electronic claim that was missing this information > or that contained dummy data, but it is up to the provider to decide > whether they are comfortable with this approach and the risk involved in > it. > > Bottom line, to be fully HIPAA compliant, providers must populate the > 837 claim with fully compliant data. This is true regardless of which > payer you send to electronically. I don't know that I've answered your > question. I have had many conversations with payers about these data > elements in particular and am happy to have further discussion with you > offline if you would like. > > Marcallee Jackson > Long Beach, CA > 562-438-6613 > > > -----Original Message----- > From: Anthony Mercaldi [mailto:[EMAIL PROTECTED]] > Sent: Monday, October 14, 2002 7:40 AM > To: [EMAIL PROTECTED] > Cc: 'Anne Romer' > Subject: Re: Missing Elements on an HCFA 1500 > > Hi Everyone, > > I would believe that any fields that can not be collected from a HCFA > 1500, > should be sorted out from the 837 HIPAA IG, and reviewed. How can my > providers submit data they don't have. So either these fields have to be > reviewed, and a new form has to be created, or HIPAA is going to have to > change the dataset(min required). This seems like the only logical > remedy to > me. What do you think about this, and can someone in the group get the > response about the missing data to HIPAA? > Either we are going to start collecting this data, or HIPAA must change. > Someone has to give! > > Thanks > Anthony Mercaldi > CTO > Innovative Computer Technologies, LLC. > > ----- Original Message ----- > From: "Marcallee Jackson" <[EMAIL PROTECTED]> > To: <[EMAIL PROTECTED]> > Cc: "'Anne Romer'" <[EMAIL PROTECTED]> > Sent: Sunday, October 13, 2002 2:34 PM > Subject: RE: Missing Elements on an HCFA 1500 > > > > 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. 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