The clearinghouse is the Business Associate of the payer, and as such, is empowered to do anything the payer wants it to do and could have done for himself. It's problematic if the converse is true: could a payer do for himself what is permissible for the business associate to do for him? - like convert non-standard input to standard??!!
The concern would be irrelevant if the provider used a non-standard claim in the first place - the "No Adverse effect" rule, � 162.925(a), doesn't apply to non-standard transactions. Your example of eligibility checking is what the FEE paper calls an "Application Level Pre-Edit Result." By moving the edit to the "front-end" (how can you get any more "front-end" than the clearinghouse?), you have actually saved the provider a lot of grief - she potentially gets some kind of feedback sooner in the process, and thus can expedite repairing her claim. I'd say that's goodness. The transaction is not being rejected simply because it is a standard transaction - a violation of �162.925(a) - but rather because the patient is not eligible; it doesn't matter that the claim never made it to adjudication or the back-end at the payer's site. The claim would presumably have been rejected (somewhere) even if it had arrived on paper or in a non-standard format - thus preserving "equal-treatment" of the standard transaction. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Marcallee Jackson" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Sent: Friday, 15 November, 2002 11:42 AM Subject: RE: Payer Edits Is it actually written somewhere that a payer can't reject a claim that meets all the requirements of the implementation guide but not adjudication edits they have pushed to the front-end? For example, some health plans provide eligibility files to clearinghouses that then reject claims up front if the patient is not eligible. Marcallee Jackson 562-438-6613 --- 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
