Edward A. Hafner
Chief Technology Officer
Foresight
Corporation
+1.614.526.4328
--------Original Message-----
From: Patricia Hamby [mailto:[EMAIL PROTECTED]]
Sent: Friday, November 15, 2002 4:15 PM
To: WEDI SNIP Testing Subworkgroup List
Subject: RE: Payer Edits (Type 7 or 8)When did a level 8 come into existence? Are these the Claredi levels? Level 7 was trading partner. If there is a level 8, would someone please send me a link? Thanks!Patricia Hamby
HIPAA Compliance Project Manager
XANTUS Healthplan of Tennessee, Inc.
(615) 463-1612, office
(615) 279-1301, facsimile--------Original Message-----
From: Thaler, Patrice M [mailto:[EMAIL PROTECTED]]
Sent: Friday, November 15, 2002 11:55 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:[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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