Julie: I assume you mean "DDE" when you say "direct internet capabilities." If so, that's great! ...for bug food (see the Business Issues discussions on DDE).
But that doesn't have much to do with the standard transactions mandated by the HIPAA TCS rule. Except maybe these spiffy new DDE capabilities set the expectations for the performance and detail required by real-time X12 standard transactions. How are payers coming along on real-time EDI? Doesn't that have to be done by 2003-10-16? William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Julie Thompson" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Sent: Saturday, 16 November, 2002 10:42 PM Subject: Clearinghouses - 276/277 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 --- 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
