RE: VALIDATION or Certification

[Marcallee Jackson]

I think CMS requires this of their intermediaries and contractors.  CMS does this as a CE and the Business Associate relationship of the contractors.  It is a way to show the BA’s are doing what they’re supposed to.  CMS does not require that the intermediaries require it of their trading partners.    -----Original Message----- From: David Frenkel [mailto:[EMAIL PROTECTED]] Sent: Monday, December 02, 2002 3:38 PM To: WEDI SNIP Testing Subworkgroup List Subject: RE: VALIDATION or Certification   Margaret, Somebody maybe has an update but the latest I am aware of is that CMS is requiring organizations that send claims transactions to them must be certified through Claredi.  Even though this requirement is not legislated it has become a business requirement of CMS.   http://cms.hhs.gov/manuals/pm_trans/AB01169.pdf   Regards,   David Frenkel Business Development GEFEG USA Global Leader in Ecommerce Tools www.gefeg.com 425-260-5030 -----Original Message----- From: Margaret Murphey [mailto:[EMAIL PROTECTED]] Sent: Monday, December 02, 2002 2:35 PM To: WEDI SNIP Testing Subworkgroup List Subject: RE: VALIDATION or Certification   While I am hesitant to get involved in this controversy, I would like to add a slightly different perspective on Certification. While I, as a payer, am open to the concept, it does appear that certain vendor(s) are "self-appointed authorities" on how to implement each transaction.   Many in the payer community that are designing and developing these TCS are exchanging notes and realizing that different vendors are giving different results, based on their individual interpretations - maybe even incorrect results. Am I way off base in feeling there really is no such thing as Certification - i.e. the Govt doesn't require it, doesn't recognize it, and perhaps most importantly, doesn't regulate it?   Testing with a third party is always beneficial. And I do agree there is pressure in the marketplace to "Certify" but where is this pressure coming from? Vendors?   These opinions are my own and do not represent any formal position of my employer. Thank you. Margaret Murphey (206)268-2348   -----Original Message----- From: Marcallee Jackson [mailto:[EMAIL PROTECTED]] Sent: Monday, December 02, 2002 10:30 AM To: WEDI SNIP Testing Subworkgroup List Subject: RE: VALIDATION or Certification Patrice-   I agree that for the purpose of HIPAA certification, 1 – 7 is sufficient.   Regarding the use of real or false testing data – there is tremendous pressure on vendors and clearinghouses to get “certified”.  This has nothing to do with the time saving aspects of testing.  It’s done almost solely to satisfy the demands of a market place that have been led to believe that a vendor’s certification is crucial to the success of their HIPAA project.   This despite the fact that the market has no idea what certification actually means.  It would be relatively easy for a vendor to run through the certification exercise without ever actually sending or receiving a compliant transaction using the software product they’re supposed to be supporting.  It would satisfy the market in a big way to do so.  Now they have months of benefiting from “certification” and enough time to actually implement the real thing (without certification).  I know most vendors are honest business folk who would never consider this but one bad apple could give certification a bad name.       -----Original Message----- From: Thaler, Patrice M [mailto:[EMAIL PROTECTED]] Sent: Monday, December 02, 2002 10:01 AM To: WEDI SNIP Testing Subworkgroup List Subject: RE: VALIDATION or Certification   Regarding 1-2 below: In my presentation I was trying to show that testing for types 1-7 is good enough. The industry already submits most claims electronically. Most providers have figured out business rules (e.g. that the date of death must not be before date of birth.) There will be a few new providers to this process and long term it might be good to have vendors check for business rules - but for now I am approaching this as the 80/20 rule. If I can get my claims or any other transaction through type 1-7 through a vendor tool -  then I should be good to go. Also, WEDI/SNIP is about HIPAA compliance not necessarily about business issues. Here is a sentence from SNIP mission "The WEDI HIPAA SNIP Task Group has been established to meet the immediate need to assess industry-wide HIPAA Administrative Simplification implementation readiness and to bring about the national coordination necessary for successful compliance" I do not believe this group was tasked with solving all health care issues. Regarding 5 below: I believe the statements made about "wondering if the CE used real data or did they create them artificially" just takes us down the path of the old paradigm - Don't trust your trading partner. I personally am beyond wondering if my payer REALLY tested a real 835. If they took the time to explain to me that they tested and passed type 1-7 edits then I think they are good to go. What would be a reason for them to lie? To lengthen our testing time? To increase our costs? I don't think so. Patrice Allina Hospitals and Clinics -----Original Message----- From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]] Sent: Tuesday, November 26, 2002 12:15 AM To: WEDI SNIP Testing Subworkgroup List Subject: Re: VALIDATION or Certification Marcallee, Thank you.  Now we are getting back on track. Let me address your points. 1. and 2.  There are a number of good reasons why transactions that are correct from the EDI perspective and from the HIPAA IG perspective will fail the business use of the transaction.  For instance, if the dates are out of "sequence", there will be no HIPAA errors detected (HIPAA does not require that the date of birth be before the date of death) but the transaction could very well fail the business logic.  A transaction without HIPAA errors is not necessarily a good business transaction.  If you are interested, I can get you more specifics out of band.  The example was just that, an example, but you get the feel, right? 3. What is a claim?  Is it the entire 837 with hundreds of 2300 loops, or is it each one of the 2300 loops?  From the business perspective of healthcare, it is each one of the 2300 loops.  From the EDI perspective, it could well be the entire 837.  It would be nice to get a clarification from HHS on this, as it could very well affect the penalties.  I believe the covered entities are required to have perfect claims, but we need to know the scope of a claim. See point #4.  As for the certification, both should be measured, how many 2300 loops are good and how many ST-SE transactions are good.  The number of 2300 loops per ST-SE is another important metric.  Of course, I am assuming that all transactions must at least be compliant with X12 syntax or the whole ST-SE would be bad.  But, will a bad ZIP code cause an entire 837 to be bad even if it only happens in one out of 10,000 claims?  I say that is too drastic a position. 4. Excellent point.  What is the threshold to claim "compliance" ?  Can I claim compliance because 1% of my claims are correct?  How high should it get?  Can I claim compliance if my correct claim percentage is 50%, 75%, 85%, 90%, 95%, 97%, 99%?  I just picked some numbers.  Who has the answer to this one?  Currently the industry operates at around 95% - 97% correct claims.  In fact, when a provider tests with Medicare they are supposed to be at least 95% clean before going to production.  So, is that the threshold?  Or has HIPAA become 100% clean or nothing?  I would like to suggest that SNIP makes some consensus recommendations in this area.  Lacking an industry consensus, it will be left up to the trading partners to set their own thresholds. 5. How do we know the certified entity used real data?  First they should be required to only use real data by contract.  Then the certification should disclose how they obtained the certification.  How many transactions they certified?  Was it only a handful, or was it a real substantial number of transactions.  It is very difficult to create large numbers of test claims (large being a relative measure, depending on the entity)  My gut feeling (not very scientific) tells me that the number of claims certified should correspond to about one week worth of business or more.  Then, if the tested transactions were artificially created, they will probably be monotonous, and that should be reflected in the details of the certification.  The details of the certification should represent a real live situation for that provider, including the quantity and types of claims (quality) that represents that specific provider.  If the certification discloses these facts, then cheating the system by certifying concocted data becomes self defeating. Do we have other assertions? Kepa On Monday 25 November 2002 10:16 pm, Marcallee Jackson wrote: > Rachel - My first message was my way of saying "cool it".  I know that > you know there are few on the list that enjoy a good debate the way I > do, so I'm not going to take your comments on that personally.  I'm also > not going to beat a dead horse so let's move on to the issue of > "certification". Separating product from process, if I understand the > assertion being made for certification, it is that: > > 1.  Certification summarizes for the tester the results of the business > scenarios included in the test. > 2.  Certification allows an aggregate report of capabilities, thereby > protecting PHI. > 3.  Certification assumes a less than 100% compliant file is to be > expected and so the pass rate should be identified and clients should be > certified if even one transaction proves to be compliant. > > But I don't understand a few things: > > 1.  In the example given earlier, the provider was able to produce HIPAA > compliant primary claims but not secondary claims.  Shouldn't the > secondary claims have failed the test? > 2.  89% of consultations failed certification.  Shouldn't those have > failed the test? > 3.  Is it OK to be compliant with some of the transactions you send, or > are CE's required under the law to be fully compliant? > 4.  If in fact an entity with a less than 1% pass rate can announce to > the > World that it has met "certification" requirements through a third party > testing and certification authority, what does that mean for the > industry? > 5.  Doesn't certification imply some independent analysis and > verification of validity?  If so, how do we know that the certifying > entity used real data?  What's to stop a vendor, provider or payer from > building rather than producing a compliant transaction and certifying > it?  > > Hope this sets an example of vendor free jargon and assists in the > discussion on this topic. > > Marcallee --- The WEDI SNIP listserv to which you are subscribed is not moderated. 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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 --- 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 --- 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 --- 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 --- 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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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 --- 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. 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