Chances are your clearinghouse has a very liberal interpretation of the IG and sees all situational data elements as optional. They are probably concerned more with the adjudication requirements of the receiving health plans, not HIPAA compliance. Maybe not though, maybe you're just lucky. Maybe they have defined the bare minimum for compliance and your claims meet that. You could do a few things:
1. Pull specific cases from your claims file. Claims you know should reject. Identify the data that you believe should cause the claim to fail and require your clearinghouse to explain how they are dealing with that data. If the clearinghouse is manipulating any data at all, they should be prepared to disclose that information to you in detail. 2. If you plan on continued translation of a non-standard to standard, require that your clearinghouse certify your transactions, post translation, with a third party on your behalf. Be certain they certify under a strict interpretation, otherwise your really only checking compliance with edit types 1&2. You probably want 1-6. 3. Accept what they are telling you. Be certain they have tested with your major payers. Call the payers and be certain the clearinghouse meets the payer's requirements and cross the non-compliant bridge when/if you come to it. If your clearinghouse is meeting the needs of all its trading partners, complaints aren't likely to occur for quite some time. Even then, there's still a lot up for interpretation. Your organization is the CE, you decide on the acceptable level of risk. If you expect your clearinghouse to meet the strictest interpretation, the clearinghouse should do that. Of course, you will probably have to find a way to provide more data than you do today and you should be prepared to pay your clearinghouse, the cost dependant on the extent to which it must go to assist you in meeting compliance. Hope that helps. Marcallee Jackson 562-438-6613 -----Original Message----- From: Mimi Hart [mailto:HartAM@;crstlukes.com] Sent: Thursday, November 07, 2002 8:05 AM To: WEDI SNIP Testing Subworkgroup List Subject: Concern in regards to "testing" I would appreciate some input on a concern I have in regards to "testing" with clearinghouses. One of our clearinghouses has sent us documentation that they are "testing" our current data stream and they will let us know which of the claims will fall out due to not being compliant. Wonder of all wonders, we have not added a single data field to our claims, but almost all are passing the tests. Having read the IG guides and completed a gap analysis, I understand that this cannot be. But it is VERY confusing to our systems analysts and CBOs when I tell them we have problems and the word they are getting from the clearinghouse is very different. Any suggestions on how to handle this? ********************************************* This message and accompanying documents are covered by the Electronic Communications Privacy Act, 18 U.S.C. �� 2510-2521, and contain information intended for the specified individual(s) only. This information is confidential. 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