Perhaps we should steer clear of words like "required" - that sounds too much like an implementation guide!
For example, in the example "edit" for the 837 Professional Claim, it says loop 2310B (rendering provider) is required - even though it subsequently says we'll make do with the billing provider! But the IG makes 2310B out to be needed mostly in order to differentiate a human provider from the pay-to provider at 2010AB, if the latter is a corporate entity. It seems like the companion guide "edit" is requiring something in a case where the underlying HIPAA IG does not. If I don't have myself tied around an axle here reading the situational loops, I'd say you have no choice but to accept an 837P with no 2310B (assuming the rendering provider human is the pay-to provider). Also, I would suggest that companion guides not repeat any requirements already in the HIPAA IG; e.g., [2310B is] Required if different from billing/pay-to provider. You may assume that the reader has access to the HIPAA IGs or a fine desktop product which displays the guides. Be as sparse in "demands" or "suggestions" as possible, in order to make the "companion" guide more defensible. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Thaler, Patrice M" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Sent: Friday, 15 November, 2002 12:55 PM Subject: RE: Payer Edits (Type 7 or 8) 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:wkammerer@;novannet.com] 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 --- 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
