Ralph, It sounds to me like your proprietary remittance transactions is accomplishing two tasks: - Remittance advice information - Claim status information on suspended claims
The first task can be accomplished with the HIPAA 835 transaction. The second task can be accomplished with an "Unsolicited claim status" or what is now known as "Claim Acknowledgment" using the 277 transaction in a mode that is not the HIPAA mode. There are a couple of implementation guides put together by X12 for this very purpose for version 3070 and version 4040. You could use these non-HIPAA transactions for your suspended claim reporting, and they will be much easier to use than the 835. Using the 835 for suspended claim reporting could result in a non-compliant 835, which could be problematic. Go to the wpc-edi web site and under healthcare (not HIPAA) you will find a draft version of the 277 both for 3070 and 4040. In a couple of weeks or so you should find the final version of the 3070 guide, approved during the X12 meeting in Miami this week. And around December you will find the latest draft of the version 4040 of this transaction. If I was in your shoes, I would implement the 277 version 4040 instead of version 3070, even knowing that there is a new draft coming up in December and that it will not be approved as final until the February X12 meeting. The December draft is what will be going for final approval in February, after the comment period. There could be some minor changes. Keep in mind that implementing from a draft guide means that there could be some changes... Kepa On Friday 11 October 2002 08:59 am, Mazza, Ralph wrote: > 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? > > > ********************************************************************** > 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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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.
