Dr. Larry, 45 CFR § 162.925(a)(1) says "If an entity requests a health plan to conduct a transaction as a standard transaction, the health plan must do so."
And § 162.900(b) says "[a] health plan must comply with the applicable requirements of subparts I through R..." Then Subpart L (which is between I and R) —Eligibility for a Health Plan - names the transaction, and § 162.1202(b) defines the 270/271 as the standard for Dental, professional, and institutional Eligibility inquiries. Of course, none of this probably means anything. Because nothing is as obvious as it first appears. When all is said and done, probably only little providers who use fax software on their laptop are subject to the full fury of the HIPAA rules and regs. I'm sure payers have found some loophole that says they don't have to support the standard eligibility transactions, if only because they can claim they're not a covered entity for the instant someone comes along wanting to exchange 270/271s. That's my cynicism showing through. As Doug has averred, even if the plan does support the standard eligibility transactions, no one says they have to be very detailed. As a matter of fact, some payers will probably have a 271 response that basically tells you to call their phone number or use their Web-based DDE system. If the DDE system can give instantaneous answers, you'd think the EDI equivalents would have to be just as fast and useful, because of the no-incentive rule at § 162.925(a)(4). But there's a catch: that only applies if the payer attempts to bribe you to use its DDE system by offering you Super Bowl tickets. In short, don't get your hopes up. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Doug Webb" <[EMAIL PROTECTED]> To: "WEDI SNIP Transactions Workgroup List" <[EMAIL PROTECTED]> Sent: Wednesday, 05 February, 2003 03:05 PM Subject: Re: Convincing healthplans of the need to support 270/271 Our gurus can quote chapter and verse, but the basic rule is that a Health Plan MUST support 270/271 AND 276/277 AND 278 AND 820 AND 834 AND 837/385 if requested by the provider, and they do the business function at all. Thus, the only way they can get out of supporting 270/271 is by not supporting any type of eligibility inquiries (and, if they accept claims, I don't see how a claim could not be classified as an inquiry about eleigibility -- getting paid says "Yes, the patient was eligibile" -- getting denied may be for the reason "the patient was not eligible") The opinions expressed here are my own and not necessarily the opinion of LCMH. Douglas M. Webb Computer System Engineer Little Company of Mary Hospital & Health Care Centers [EMAIL PROTECTED] ----- Original Message ----- From: <[EMAIL PROTECTED]> To: "WEDI SNIP Transactions Workgroup List" <[EMAIL PROTECTED]> Sent: Wednesday, 05 February, 2003 12:47 PM Subject: Convincing healthplans of the need to support 270/271 We have relationships with many health plans for eligibility processing. One in particular has told us that their HIPAA consultants told them that they don’t need to worry about anything but the rosters they provide doctors/groups. They seem to think online eligibility ANSI requirements are nice but not something they have to worry about. Can you tell me/give me the section of HIPAA doctrine that talks about this so I can share with them and make him aware of why they needs to pay attention to this topic? This is not an isolated occurance. Many healthplans I talk to do not feel the need to support the 270/271. Thanks for your help with this and your insights. Larry A. Saltzman, MD' CEO Insurance Benefit Spot Check, Inc. Sacramento, CA --- 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
