Well, here's two cents from the payer perspective.
Our 837 companion document was made available to our direct submitters last
month for precisely some of the reasons others have raised. Our intent was
not to replicate, or contradict, or take the place of the IGs - it really
is a companion document. Our companion document states clearly, "For use
with the ASC X12N 837 IG and Addenda..." We would like our submitters to
be intimately familiar with the IGs. To that end, we have not rehashed the
entire layout in our companion document, and have included only situational
data elements in describing our requirements. If it's a required data
element in the IG, it's required - why print it redundantly in our
companion document?
We have tried to give our submitters significant lead time to complete
their development so we both can have ample time to test.
As with other states, there is also a collaborative project underway here
in Massachusetts.
Rob Wald
_____________________________
Rob Wald
HIPAA Program
Tufts Health Plan
617-972-9400 x3284
[EMAIL PROTECTED]
____________________________
"Miriam Paramore"
<miriam.paramore@hipaasu To: "WEDI SNIP Testing
Subworkgroup List" <[EMAIL PROTECTED]>
rvival.com> cc:
Subject: RE: Payer Edits (Type
7 or 8)
11/15/2002 02:18 PM
Please respond to "WEDI
SNIP Testing
Subworkgroup List"
We are doing a payer companion guide collaboration project in KY. There
is a national effort being formed between WEDi and CAHQ, but I have little
detail at this point. Our KY group, HAWK, is presenting a panel in
PHoenix. Would very much support national effort and/or tying together RSA
efforts. This is most helpful to national payers. Providers are well
served by State/Regional efforts, as their payer mix is mostly addressed at
that level.
Best Regards,
Miriam J. Paramore
President & CEO
PCI: e-commerce for healthcare
9001 Shelbyville Road
iTRC Building
Louisville, KY 40222
502-429-8555
www.hipaasurvival.com
===========================================
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-----Original Message-----
From: David Frenkel [mailto:gefeg@;att.net]
Sent: Friday, November 15, 2002 1:26 PM
To: WEDI SNIP Testing Subworkgroup List
Subject: RE: Payer Edits (Type 7 or 8)
Patrice,
There is a similar effort going on in the Seattle area among some of
the big players to create companion guides and I understand there are
other regional efforts as well like yours in MN. I wonder if it
might be of national interest to create a SNIP group to discuss these
regional companion guides being created to find commonality that
might be incorporated into future national implementation guides and
discuss regional issues.
Regards,
David Frenkel
Business Development
GEFEG USA
Global Leader in Ecommerce Tools
www.gefeg.com
425-260-5030
-----Original Message-----
From: Thaler, Patrice M [mailto:Patrice.Thaler@;allina.com]
Sent: Friday, November 15, 2002 9:55 AM
To: WEDI SNIP Testing Subworkgroup List
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
----- 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:ehafner@;foresightcorp.com]
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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