Miriam-
Though more information may be needed, assuming the provider network is an IPA:
In your scenario the provider-to-BA (agent of the payer) exchange must be done in the standard but the agent-to-payer transaction is not covered by HIPAA. Since the second company is performing health plan functions, it is likely the BA of the second company or Medicaid when acting in the health plan role. It may also be the BA of the provider. This is a common "delegated" model used in managed care. When this company receives and pays a claim, it does so acting as a payer on behalf of the health plan. If the second company then reported post adjudicated claims data to the plan or its agent, the first company, it could send the data using any method or format. A claim/encounter defined under HIPAA is a transaction from provider-to-payer.
Clear as mud?
Marcallee
----- Original Message -----
From: "Miriam Paramore" <[EMAIL PROTECTED]>
To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]>; <[EMAIL PROTECTED]>
Sent: Tuesday, March 04, 2003 1:13 PM
Subject: BA to BA
>
> First company is a BA of Medicaid. Does X12 with Caid. Second company
> is
provider network that performs health plan functions and communicates with first BA for encounter reporting only. Does X12 with providers. Does BA TO BA exchange have to be X12?
>
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