Marcallee, This is one of the scenarios that we are working with on the 824 IG. One of the departments at the state of Ohio has already implemented this. If you receive a batch of 5000 claims and 300 of them are not HIPAA compliant, what should you do? You really don't want to kick back the whole batch.
- Send 997 stating the file was received with appropriate X12 syntax. - Send 277 unsolicited to acknowledge the receipt of the good claims and the claim numbers that you assigned to them for future reference when using the 276/277 - Send 824 for the 300 bad claims thus not accepting them due to HIPAA non-compliance. With the 824 transaction you can point to where the errors happened also. John N. Huff, PAHM >Response from Marcallee: > >Yes it does! This is exactly what we need to implement to get the job >done. Will you post it to the list? > >Thanks for responding. > >Marcallee -----Original Message----- From: Marcallee Jackson [mailto:[EMAIL PROTECTED]] Sent: Wednesday, December 04, 2002 8:33 PM To: WEDI SNIP Testing Subworkgroup List Subject: RE: Does one bad transaction spoil the whole transaction set? Julie- Many, many, many providers will be exempt from Medicare's EDI requirement and CMS has not even really begun speaking formally about enforcement of that. Many exempted providers aren't really all that small either and together their paper volume could nickel and dime a payer to death. But even with ASCA's requirement there are few payers who carry a stick as big as Medicare and large providers aren't always as accepting of strict, hard to comply with rules set by commercial plans where contracts are negotiated. Now there may be lots of payers who "plan" to reject transaction sets but you know what they say about the best laid plans . . . I'm aware of many payers that bought translators and "planned" to implement 100% compliant transactions when they brought the system up. Most are very unhappy to learn that in the real world of HIPAA implementation, this doesn't work unless you plan to: A. Bring up the system on October 17, 2003 B. Bring up the system and have very (and I mean very) few transactions process through it for many months to come Most that I talk to, once they understand the impact their original plan would actually have on their claim volume and their HIPAA implementation, change their plans from hard-line to real world. I predict the same result to the hard line approach of rejecting transaction sets. It's easier to sit in a meeting and talk about rejecting transaction sets for one bad transaction. It's harder to turn the switch and watch your EDI volume drop. On average, even the best billing entity will experience about a 5% - 15% error rate. Initially, that number is expected to increase with HIPAA as we all make adjustments to transactions or edits. Have your clients analyzed their in bound files to see, if they had this policy in place today, how many files would make it through the front-end system? If they didn't reject at the claim level and instead rejected whole files, how many files could make it through? We can't continue down the compliance path with our blinders to the real challenges of HIPAA implementation. The "it'll be daunting but here we go" approach no longer works. What becomes clearer each day is that it's damn near impossible, full compliance by October 16, 2003 won't happen and it's fast approaching time to talk about how close we can get to 100%. Not that I expect CMS to discuss that in an FAQ. -----Original Message----- From: Julie Thompson [mailto:[EMAIL PROTECTED]] Sent: Wednesday, December 04, 2002 5:47 PM To: WEDI SNIP Testing Subworkgroup List Subject: Re: Does one bad transaction spoil the whole transaction set? - used to be defining a health care claim within the context of the 837 implementation guide Good to hear from you Marcallee! By Federal Law, Medicare requires 837 compliance by October, 2003. If you are compliant with Medicare, why not all other payers? So the paper option has been pretty much eliminated. We are AGREE, the task at hand is more than DAUNTING, but here we go! Some implementation will go smooth as silk, others will take a while. IT Developers are familiar with lengthy, complicated testing processing and are well trained for these jobs. I am not so concerned about element by element validation, but by the last items on the list....integration. But this is a lengthy discussion. All trading partners are going to as much work done as they can in the short time left by October. Keep in the mind, the implementation will appear in waves, NOT just one fell swoop. This will be helpful. Julie A. Thompson From: "Marcallee Jackson" <[EMAIL PROTECTED]> Reply-To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Subject: Re: Does one bad transaction spoil the whole transaction set? - used to be defining a health care claim within the context of the 837 implementation guide Date: Wed, 4 Dec 2002 17:17:50 -0800 This is not a clearinghouse issue to fix. What if the 300,000 claims are coming from an entity that is not a clearinghouse? What if it's 3000 files of 100 claims each with 1 problem? Very, very, very few submitters have front-end editing to ensure compliance, with HIPAA or payer specific requirements, so payers who accept direct transactions can expect to see errors in many of the transaction sets they receive. When it comes to real life production, hard-line approaches like this simply will not work. I think your clients might need to get ready to receive an awful lot of paper. I know of a good scanning solution if you think that might help ;). Marcallee -----Original Message----- From: Julie Thompson [mailto:[EMAIL PROTECTED]] Sent: Wednesday, December 04, 2002 4:57 PM To: WEDI SNIP Testing Subworkgroup List Subject: RE: Defining a health care claim within the context of the 837 implementation guide Isn't it the job of clearinghouses to fix these issues? A compliant transaction will use dummy or default values in order to achieve compliance. Yes, this is the plan for numberous BCBS across the U.S., including several of our clients. Julie A. Thompson Vice President, Concio From: "Marcallee Jackson" <[EMAIL PROTECTED]> Reply-To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Subject: RE: Defining a health care claim within the context of the 837 implementation guide Date: Wed, 4 Dec 2002 16:46:17 -0800 Yeah well there're the FAQ's and then there's real life. You're going to have a hard time convincing many of us that Medicare intermediaries will be rejecting a batch (transaction set) of 300,000 claims (transactions) because claim # 299,996 is missing a zip code. Are you seeing this in real life implementations and if so, can you share the names of the carriers? -----Original Message----- From: Julie Thompson [mailto:[EMAIL PROTECTED]] Sent: Wednesday, December 04, 2002 9:32 AM To: WEDI SNIP Testing Subworkgroup List Subject: RE: Defining a health care claim within the context of the 837 implementation guide HHS is the group to answer the question of whether to accept a non HIPAA compliant transactions in production (X12 alone is NOT compliant). I have spoken with Stanley Nachimson and non compliant production transactions are subject to fine for both the transmitting and the receiving partners. There was an HHS FAQ I am unable to find the FAQ stating the above, but here are some other helpful related HHS FAQs. To submit a questions for publication go to: http://aspe.hhs.gov/admnsimp/bannertx.htm HERE ARE SOME VERY HELPFUIL HHS FAQs: HHS FAQ: Question How would someone file a complaint against a covered entity? Answer CMS will develop a web-based complaint management process, and will provide information on this process as part of our HIPAA outreach activities. Question What will the enforcement process look like? Answer The enforcement process for HIPAA transactions and code sets (and for security and standard identifiers when those are adopted) will be primarily complaint-driven. Upon receipt of a complaint, CMS would notify the provider of the complaint, and the provider would have the opportunity to demonstrate compliance, or to submit a corrective action plan. If the provider does neither, CMS will have the discretion to impose penalties. Question Who will enforce the HIPAA standards? Answer The Department of Health and Human Services (HHS)has determined that CMS will have responsibility for enforcing the transactions and code set standards, as well as security and identifiers standards when those are published. CMS will also continue to enforce the insurance portability requirements under Title I of HIPAA. The Office for Civil Rights in HHS will enforce the privacy standards. HHS FAQ: Who is required to use the standards? All private sector health plans (including managed care organizations and ERISA plans, but exlcuding certain small self administered health plans) and government health plans (including Medicare, State Medicaid programs, the Military Health System for active duty and civilian personnel, the Veterans Health Administration, and Indian Health Service programs), all health care clearinghouses, and all health care providers that choose to submit or receive these transactions electronically are required to use these standards. These "covered entities" must use the standards when conducting any of the defined transactions covered under the HIPAA. A health care clearinghouse may accept nonstandard transactions for the sole purpose of translating them into standard transactions for sending customers and may accept standard transactions and translate them into nonstandard transactions for receiving customers. From: "Marcallee Jackson" <[EMAIL PROTECTED]> Reply-To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Subject: RE: Defining a health care claim within the context of the 837 implementation guide Date: Mon, 2 Dec 2002 09:50:01 -0800 I agree with you that once in production - compliance may or may not be a critical issue but the discussion started out around certification. Take a look at the message posted under that subject and let me know your thoughts. Thanks -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Monday, December 02, 2002 9:30 AM To: WEDI SNIP Testing Subworkgroup List Subject: Re: Defining a health care claim within the context of the 837 implementation guide I guess there's no doubt that the 2300 loop is a "claim" - 'cause it's right there in the HIPAA IG called "Claim information." But in any event, where does it say that you're going to get into trouble if you accept a claim (or 837) which is not perfectly "compliant"? I see in the Rule where it says the Plan has to accept standard transactions. Therefore, I can imagine a provider who's sent a perfectly compliant 837 - which has been rejected - now has a leg to stand on when she complains to HHS about the big bad payer. Thus, it certainly behooves the payer to be able to accept any compliant claim. But whoever is going to complain when the payer accepts and pays claims with bad zip codes, or no service facility address (how would anyone know it was needed anyway), or phony newborn weights when it doesn't otherwise require them? Before penalties kick in, I would expect someone to have been harmed - i.e., the provider. A provider who sends an otherwise compliant claim is harmed when the payer refuses to accept it - she can't make it any more "compliant," can she? Her only other choice with an obstinate payer would be to submit paper or else she won't get paid. And it's unlikely a payer is going to complain about "non-compliant" transactions from a provider; if he chooses not to process them, and if the provider whines, he can always tell her to go check out her transaction with Claredi or whoever to satisfy herself that the transaction is slop. Is this "penalties" business more HIPAA-hysteria? William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Rachel Foerster" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Sent: Monday, 02 December, 2002 12:03 PM Subject: Defining a health care claim within the context of the 837 implementation guide Marcallee, I propose that you change the subject line for this specific message thread, since it appears the issue is not one of validation or certification, but rather, Rachel Foerster ----- Original Message ----- From: "Marcallee Jackson" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Sent: Monday, 02 December, 2002 10:52 AM Subject: RE: RE: VALIDATION or Certification My initial suggestion that, for the purpose of this message string, we define a claim as each 2300 loop was based on item 3 from Kepa's earlier message On Monday, November 25, 2002 10:15 PM Kepa Zubeldia wrote: 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. So sounds like in terms of defining a claim - we are in agreement that each 2300 loop would equal a business transaction a/k/a claim. --- 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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