I have heard of provider edits. In our collaborative we have provider edits in our 835 companion guide.
I want to be clear that I was extremely nervous about creating companion guides. I am a believer in STANDARDS. but I hope you can see by reading the examples below our payers are not changing the standards - just helping providers (or payers) know their logic. Does anyone think these are changing the standard?
Here are sample edits for the 837 Professional
Claim
REF02 Prior Authorization or Referral Number
2300
*If number is incorrect, the data will be dropped and the auto match
process in our claims processing system will obtain the correct
number.
NM1RENDERING PROVIDER NAME 2310B
*Required for all
providers.
*If not submitted billing provider will be used in
adjudication.
*Required if different from billing/pay-to
provider.
*Application rejects if claim does not contain rendering
information in one of the provider loops.
*Required if different from Billing
Provider (Loop 2010A)
*Required if different from Billing Provider (Loop
2010A)
-----Original Message-----
From: William J. Kammerer [mailto:[EMAIL PROTECTED]]
Sent:
Friday, November 15, 2002 11:30 AM
To: WEDI SNIP Testing Subworkgroup
List
Subject: Re: Payer Edits (Type 7 or 8)
Perhaps Ed was just
being circumspect. Indeed, all partner specific
edits I've ever heard
of are "payer-specific." Has anyone ever heard of
a provider mandating
specific things a payer is to send to her (say, in
the 835 or 277)?
Hence, "payer-specific" is far more honest.
Can someone provide concrete
examples of these "payer-specific" edits? -
And how they might be phrased in
a "companion" guide? You know, I can
imagine things like a payer saying "we
need the plan ID for the
subscriber in order to process the claim, and our
plan numbers look like
this..." Or "we just use the first 4 diagnosis
codes you might
specify." And maybe even parenthetically, the
payer could say where
these things occur by loop, segment and element.
But if the "companion
guide" starts to look like a duck, quack like a duck,
and waddle like a
duck - it probably is a duck, i.e., an "implementation
guide." Then its
legality is problematic.
William J.
Kammerer
Novannet, LLC.
Columbus, US-OH 43221-3859
+1 (614)
487-0320
----- Original Message -----
From: "Rishel,Wes"
<[EMAIL PROTECTED]>
To: "WEDI SNIP Testing Subworkgroup List"
<[EMAIL PROTECTED]>
Sent: Friday, 15 November, 2002 11:33
AM
Subject: RE: Payer Edits (Type 7 or 8)
I don't know the history on
this, but if I am a provider sending to a
clearinghouse, and the
clearinghouse is adding edits beyond the IG, it
is doing so on behalf of the
payer.
Since the same clearinghouse will enforce different edits on
behalf of
different payers, "payer-specific" seems more to the
point.
-----Original Message-----
From: Ed Hafner [mailto:[EMAIL PROTECTED]]
Sent:
Friday, November 15, 2002 8:00 AM
To: WEDI SNIP Testing Subworkgroup
List
Subject: RE: Payer Edits (Type 7 or 8)
Rama,
Partner
specific is a term I pulled out of the IG and even there it
infers that most
partner specific edits are initiated by the payer. So
you can really group
our terms together. I was being a little more
formal in respect to the
guides.
Only the explicitly documented edits in the IGs today
(Medicare,
Medicaid, and Indian Health) are being considered type 7. All
other
partner/payer specific edits outside the guides are not considered
type
7. This conversation on what to call these edits leads to one of
the
reasons for enhancing the B2B testing paper. Not to confuse the
issue,
these partner/payer specific edits really could be of any type
referring
to Kepa's response (e.g. data code lookup(5), specialty edit(6),
health
care conditional logic(4)).
Hope that
helps,
Ed
Edward A. Hafner
Chief Technology
Officer
Foresight Corporation
+1.614.526.4328
---
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