What would anyone suggest a provider do if they feel a payer "will not accept something that is valid in the guide, or that they require something the guide does not require (including situational requirements)."? My experience tells me that most providers will 'cave' to the payer demand, either because they just don't know enough about the standard or so they can get paid, thereby eroding the standard. Should the provider file a complaint to CMS stating they believe the payer is non-compliant with the data element standards defined in the guides? What else can we do to make sure the 'theory' of true standardization will be come 'reality' in October?
John Craft Partner, HCS 334-396-0833 -----Original Message----- From: Kepa Zubeldia [mailto:[EMAIL PROTECTED] Sent: Friday, February 28, 2003 9:06 AM To: WEDI SNIP Testing Subworkgroup List Subject: Re: Payers and Optional Fields Miriam, The content of the transaction is under the control of the submitter as long as the submitter is complying with the implementation guide. The theory is that a payer cannot say that they will not "accept" something that is valid in the guide, or that they "require" something the guide does not require (including situational requirements). That is the HIPAA theory. The reality, at least today, is different. Will the reality change after October 16? Maybe... But as of today, a payer that has filed for the ASCA extension, or small health plans that did not need to file for the ASCA extension, do not need to be compliant with HIPAA yet, so they can superimpose their own requirements. Perhaps that will change in October. At least it "should" change. Or is it "must" change? :-) As for the Taxonomy code, if the payer says "I need the taxonomy code because it impacts my adjudication system" then the provider MUST send it because that is what the implementation guides (Addenda) now require. Kepa Zubeldia Claredi On Friday 28 February 2003 07:08 am, Miriam Paramore wrote: > This is probably the 100th time this has been asked... but bear with > me. > > Can a payer mandate that a provider put a certain value in an optional > field? Unisys has stated that it is requiring the taxonomy code in an > optional field, and will not pay the claim unless that optional field > is present. > > I think this flies in the face of all things HIPAA standard. Isn't > that type of payer behavior expressly prohibited? Still, other payers > felt that they could get by with such a mandate as a "business rule" > between trading partners. Sounds like the dog is still getting > wagged. Best Regards, > > Miriam J. 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