Clearinghouses - 276/277

[Julie Thompson]

To all:

Please be aware many health plans have built or are in the process of building direct internet claim status capabilities for their providers.

Julie A. Thompson
Vice President, Concio






From: "Rachel Foerster" <[EMAIL PROTECTED]>
Reply-To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]>
To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]>
Subject: RE: Payer Edits
Date: Sat, 16 Nov 2002 13:18:51 -0600

Marcallee,

Yes, I do believe that the clearinghouse/payer must be able to respond to a
claim status inquiry when a claim is rejected on this basis. Since the CH is
acting as the agent of the payer, the concept of the claim making it past
the clearinghouse isn't applicable. The CH is acting in place of the payer
and as such, should be able to appropriately respond to a claim status
inquiry with a response like "the claim was denied since patient is not
eligible" or something like that, whatever the 277 IG requires.

The claim wasn't rejected for IG non-compliance.

Rachel Foerster

-----Original Message-----
From: Marcallee Jackson [mailto:[EMAIL PROTECTED]]
Sent: Saturday, November 16, 2002 10:21 AM
To: WEDI SNIP Testing Subworkgroup List
Subject: RE: Payer Edits


Thanks William. I agree.

In the case of application level front end edits such as these, do you
believe the clearinghouse/payer must be able to respond to a subsequent
claim status request for claims that never made it past the
clearinghouse?

-----Original Message-----
From: William J. Kammerer [mailto:[EMAIL PROTECTED]]
Sent: Saturday, November 16, 2002 8:17 AM
To: WEDI SNIP Testing Subworkgroup List
Subject: Re: Payer Edits

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


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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.

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