I appears that my "strike outs" did not make it through the listserv ... Here's how the paragraph should have read:
After HIPAA Provider A contracts with CH-1 to transmit 837's (electronic claims), CH-1 transmits the 837 (claim) to the payer. In turn, CH-1 accepts the payer's 835 (payment format) (as contracted by the provider), CH-1 transmits the 835 to the provider. My point here is ... I consider every provider a responsible healthcare entity that (given the correct HIPAA information) will create their own HIPAA compliant transactions. Whether or not they want to use a CH to be their "traffic cop" for sending/receiving the transactions to/from different entities ... is a business decision based on the number of health plans/payers that they deal with. I agree that the role of the CH is changing and the CH's are aware of this. Whether or not the fees they charge are reasonable is not for me to say ... everyone has to analyze their own ROI based upon their situation. The concern is whether or not we as "HIPAA-educated" organizations/consultants is presenting "all" the information to the provider so that they can make their OWN decision and not be "pressured" by other "HIPAA-educated" organizations/consultants to make a decision that benefits a business model not the provider's is something that provider's are very cautious about. Ruth Tucci-Kaufhold HIPAA Systems Analyst Co-Founder MAHI UNISYS Corporation (still not a clearinghouse) 4050 Innslake Drive Suite 202 Glen Allen, VA 23060 (804) 346-1138 (804) 935-1647 (fax) N246-1138 [EMAIL PROTECTED] -----Original Message----- From: Tucci-Kaufhold, Ruth A. [mailto:[EMAIL PROTECTED]] Sent: Monday, January 27, 2003 4:33 PM To: WEDI SNIP Transactions Workgroup List Cc: 'Chris Brancato'; Tom Drinkard (E-mail) Subject: RE: Clearinghouse Connectivity and Fees - or, Have I got a deal f or you! Now that we all have calmed down from this issue, I'd like to answer a few questions put to me on this issue: For the purpose of this discussion ... [I have underlined portions for emphasis] [(1) re: p.50314 FR TCI: 1.Electronically Transmitting Transactions. ... apply to health plans and health care clearinghouses, as well as any health care provider when transmitting an electronic transaction defined in Subpart A of 45 CFR Part 142.] [(2) re: p.50314 FR TCI: 1.Electronically Transmitting Transaction. ... However, we require covered entities to apply many of the provisions of the rule to the entities with whom they contract for administrative and other services related to the transactions, as it would be inconsistent with the underlying statutory purpose to permit covered entities to avoid the Act's requirements by the simple act of contracting out certain otherwise covered functions. With respect to health plans, a health plan is required to have the capacity to accept and/or send (either itself, or by hiring a health care clearinghouse to accept and/or send on its behalf) a standard transaction that it otherwise conducts but does not currently support electronically. For example, if a health plan pays claims electronically but historically performed enrollment and disenrollment functions in paper, the health plan must have the capacity to electronically perform enrollment and disenrollment as well as claims payment as standard transactions by the applicable compliance date of the regulation.] For me scenarios are easier to deal with ... so here goes... Before HIPAA Provider A contracts with CH-1 to accept the provider electronic claim format, convert the provider format to the appropriate payer format, and transmit the claim to the payer. In turn, CH-1 accepts the payer's payment format (as contracted by the provider), converts that format to the provider's format, transmits the provider's format to the provider. After HIPAA Provider A contracts with CH-1 to transmit 837's (electronic claims), convert the provider format to the appropriate payer format, and transmit the 837 (claim) to the payer. In turn, CH-1 accepts the payer's 835 (payment format) (as contracted by the provider), converts that format to the provider's format, transmits the 835 provider's format to the provider. With respect to the "business function" vs. Electronic Transaction ... this only applies to the payer/health plan (sorry if I mis-spoke). Example: Most health plans today, handle the business function of "claims status" over the telephone. Where the provider calls the payer/health plan's claims department to inquiry as to the status of a claims previously submitted. That function is deemed in "X12" as a 276/277 transaction pair. The payer/health plan must be able to show that they can accept and send inbound 276 and an outbound 277. See #2 above. As to the paper being generated by a CH on behalf of a provider ??? .... If the provider is sending the transaction (in any format) electronically, the CH is bound by HIPAA to convert it into the HIPAA format. See #1 above. I am not here to dispute the current million or so scenarios that exist and will continue to exist post-HIPAA. We are all striving to effectively and efficiently participate in eCommerce. The healthcare industry cannot do so without standardized transactions. For those that are "anti-HIPAA" that is okay with me but...just don't complain when claims are not paid and/or rejected. The health plans have be given the "no-choice" award in HIPAA. There are more words "must" associated with health plans than any other entity in the TCI rule. The health plans eventually have to pick one "claims entry system" that they are going to support. If the provider wants to do business on paper ... then as "adult business entities" ... will eventually pay more to have paper claims processed than electronic transaction ... again their choice and "perfectly legal". If you need an example of that ... go to the banking industry and you will find many examples of "fees for paper" all over the place. Thanks. Ruth Tucci-Kaufhold HIPAA Systems Analyst Co-Founder MAHI UNISYS Corporation (not a clearinghouse) 4050 Innslake Drive Suite 202 Glen Allen, VA 23060 (804) 346-1138 (804) 935-1647 (fax) N246-1138 [EMAIL PROTECTED] -----Original Message----- From: Chris Brancato [mailto:[EMAIL PROTECTED]] Sent: Monday, January 20, 2003 6:44 PM To: WEDI SNIP Transactions Workgroup List Subject: RE: Clearinghouse Connectivity and Fees - or, Have I got a deal f or you! Ruth, I'm not appreciating your reason for concern. This very scenario happens every day. A definition of CH in the scenario might help. These CH/aggregators I allude to are acting as clearing houses as they are taking non-standard transactions as well as providing print and mailing services. i.e., they might be a software vendor that takes proprietary, non-standard claims from their clients, translates the standard ones that are able to be submitted electronically, and submits to a bigger clearinghouse like Unisys/Envoy-then onto the payer-if they don't have a direct submitter relationship. The ones that don't or have to be sent back to the provider for additional documentation are printed out. Not a traditional CH, but a CH by definition, nonetheless. The print mailing operation of this CH then submits the paper claims to the payer direct on behalf of the provider. I personally know a state agency that is a Unisys client for electronic transactions only, the ones that can't be submitted to a payer electronically because either the payer doesn't accept them or they need additional documentation; go to paper at the aggregator-CH level. All perfectly legal, all happens everyday, can and will continue to happen. Now, eventually, hopefully that level of paper will drop especially when and if an attachment standard is agreed upon and implemented, but not anytime soon. I for one am not a convert to the religion that this will all disappear come October, 2003. Personally, this arrangement I describe to you, I predict will be increasingly common, not decreasing so because of the high touch, high services companies like this provide to the clients especially in regards to HIPAA. They don't want to deal with a CH as you say, but they'll pay additional for a PM/Service Company to do it. They just want their claims paid. No more, and certainly no less. They can and will continue to pay small transaction fees to the PM/aggregator because it saves them time and money by managing the process. They are free to see patients and generate income. --- 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-transactions 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-transactions 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/. 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