Re: Payer Edits

[Julie Thompson]

In evaluationg payer edits, please refer to the HHS FAQ on the limitations of companion documents. Simply worded, no expansion or restrictions can be applied. Such as repeat limitations by payers, or expansion of code set values (where not allowed), or restriction of the use of negative or positive dollars amounts.

See http://aspe.hhs.gov/admnsimp/faqtx.htm or the text below:

HHS FAQ: "Should health plans publish companion documents that augment the information in the standard implementation guides for electronic transactions?"

"Additional information may be provided within certain limits."

"Electronic transactions must go through two levels of scrutiny:"

"1) Compliance with the HIPAA standard. The requirements for compliance must be completely described in the HIPAA implementation guides and may not be modified by the health plans or by the health care providers using the particular transaction."

"2) Specific processing or adjudication by the particular system reading or writing the standard transaction. Specific processing systems will vary from health plan to health plan, and additional information regarding the processing or adjudication policies of a particular health plan may be helpful to providers."

"Such additional information may not be used to modify the standard and may not include:"

"- Instructions to modify the definition, condition, or use of a data element or segment in the HIPAA standard implementation guide.

"- Requests for data elements or segments that are not stipulated in the HIPAA standard implementation guide."

"- Requests for codes or data values that are not valid based on the HIPAA standard implementation guide. Such codes or values could be invalid because they are marked not used in the implementation guide or because they are simply not mentioned in the guide."

"- Change the meaning or intent of a HIPAA standard implementation guide."







From: Kepa Zubeldia <[EMAIL PROTECTED]>
Reply-To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]>
To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]>
Subject: Re: Payer Edits
Date: Thu, 14 Nov 2002 16:55:32 -0700

Patrice,

I have a different opinion. Some payer specific edits refer to situational
edits (type 4) or to line of business specific edits (type 6) or even to
limitation on syntactical requirements such as limits on loop counts or
requiring specific provider IDs that would fit within the definition of type
2 edits.

So the fact that they are payer specific does not make them into a type 8
vague group. My interpretation is that there are "HIPAA requirements" and
"payer specific requirements" and both types can be divided into the same
types 2-6. Type 1 is X12 syntax and the payers cannot define that.

Then type 7 in the "HIPAA requirements" are payer specific requirements
defined in the implementation guide, such as Medicare, Medicaid and Indian
Health. A payer specific requirement that does not fit within the "payer
specific types 2-6" would be a "payer specific type 7" sort of edit.

So, as I understand it, there is no type 8.

Does this make sense?

Kepa



On Thursday 14 November 2002 10:30 am, [EMAIL PROTECTED] wrote:
> Patrice,
>
> Yes...any payer edits that are not mentioned in the X12N implementation
> guides would be referred to as the next type of testing. Our plans are to
> delve more into that subject in the Business to Business Testing white
> paper.
>
> _______________________________________________
>
> John Lilleston
> Technical Supervisor
> Verizon Information Technologies, Inc.
> Healthcare Solutions
> 813-979-3225
> [EMAIL PROTECTED]
> http://www.VerizonIT.com/
> _______________________________________________
>
>
>
> "Thaler, Patrice
> M" To: "WEDI SNIP Testing
Subworkgroup List"
> <Patrice.Thaler@a
<[EMAIL PROTECTED]>
> llina.com> cc:
> Subject: Payer Edits
> 11/14/2002 12:26
> PM
> Please respond to
> "WEDI SNIP
> Testing
> Subworkgroup
> List"
>
>
>
>
>
>
> There are some payers that are developing their own companion guides and we
> will be testing against them with a tool prior to direct testing. Would we
> call this "Type 8" testing?
>
>
> Patrice Thaler
> Allina Hospitals and Clinics
> HIPAA Project Manager
> Phone: 612-775-9705
> Pager: 612-654-3066
> Fax: 612-775-9715


---
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/. These listservs should not be used for commercial marketing purposes or discussion of specific vendor products and services. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time.

You are currently subscribed to wedi-testing as: [EMAIL PROTECTED]
To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED]
If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org


_________________________________________________________________
The new MSN 8: advanced junk mail protection and 2 months FREE* http://join.msn.com/?page=features/junkmail


---
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/. These listservs should not be used for commercial marketing purposes or discussion of specific vendor products and services. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time.

You are currently subscribed to wedi-testing as: archive@jab.org
To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED]
If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org