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From a
provider perspective, we will take the 'one size fits all' approach to the
degree possible. We submit
claims
in 13 different states, are undergoing 19 different software upgrades to
handle
additional data elements. We have chosen to identify all of the
situational data elements that we think
apply
(i.e. our best educated guess) and then have a small subset of elements
identified as 'state specific.'
We
are in the process of comparing this analysis to the payer companion
guides and will finalize our data collection
procedures once we certify our transactions and get further
along in our payer testing. We are also
developing a
company wide training program to teach our office staff and billing staff
to collect data in
the
same way regardless of payor. If we don't need the data in the end (or it
causes problems) then we won't send it.
For
us, collecting more information is better. We are fortunate to have some
internal programming resources
that
can 'tweek' the transactions before we send them to the clearinghouse if
necessary. Should other smaller providers take the one size fits all approach,
those providers may face more difficulties if payers choose to reject
transactions that contain information they (the payer) consider to be
additional situational data (and I have seen some cases of
this.)
Well, couldn't one argue that in the case of Provider
Taxonomy codes (and other situational fields that, per the IGs, are to be
included if required for claims adjudication), a cross-payer "standard
transaction" would always contain the provider taxonomy code? (and
other...). Payers that don't use the Provider Taxonomy code
(and...) are prohibited from rejecting a claim that contains it, and
only those that need it would look at it.
From a business process perspective providers may or may not
want to take this option. (In the case of taxonomy code, my impression
is that "would not" is in some cases the definite option of choice)
But if one is focusing on having a "one size fits all" hipaa-compliant
claim, there are some areas where it's not impossible...The question, I think, is: is there a business case, from the provider
perspective, for generating a "one size fits all" claim, and the answer to
that question will vary.
TGI!F! Cy
----- Original Message -----
Sent: Friday, February 28, 2003 12:15
PM
Subject: Re: Payers and Optional
Fields
Miriam,
I hate to burst your bubble, but there have
never been standards. Our mindset has always been that these are
guides, which in turn are subject to interpretation.
----- Original Message -----
Sent: Friday, February 28, 2003 7:14
AM
Subject: RE: Payers and Optional
Fields
Thanks to all responses. Yesterday HAWK put on a
testing seminar here in
Louisville. One of the providers brought
up this specific example and said
"the standard is not a
standard". You are all correct that I incorrectly
used the word
optional.
Bottom line, if payers can require something for
adjudiation (as
situational), then there is no standard across
payers. Right? This makes
our payer data requirements cross
reference much harder (a HAWK project).
Disappointed...
Best
Regards,
Miriam J. Paramore
President & CEO
PCI:
e-commerce for healthcare
9001 Shelbyville Road
iTRC
Building
Louisville, KY 40222
502-429-8555
www.hipaasurvival.com
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This
email contains confidential information intended only for the
named
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prohibited.
-----Original Message-----
From:
Kepa Zubeldia [mailto:[EMAIL PROTECTED]
Sent: Friday, February
28, 2003 10:06 AM
To: Miriam Paramore; WEDI SNIP Transactions Workgroup
List; 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. Paramore
>
President & CEO
> PCI: e-commerce for healthcare
> 9001
Shelbyville Road
> iTRC Building
> Louisville, KY
40222
> 502-429-8555
> www.hipaasurvival.com
>
===========================================
> This email contains
confidential information intended only for the named
> addressee(s).
Any use, distribution, copying or disclosure by any other
> person
is strictly prohibited.
>
>
>
>
>
>
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