Re: Accept v. Process Standard Transactions

[Doug Webb]

Paul,   Accepting the claim means entering it into the adjudication system.  What the adjudication system does with it is determined by your business rules.  HIPAA does not mandate what codes you pay for, and the completeness necessary to determine the proper payment.  Improper coding is probably the most frequent cause of claim rejection, and it will continue to be so.   In the same manner, accepting a query means doing the search requested and forming some type of response.  "Not Found" is quite acceptable if the information given does not allow the query to succeed.   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]   "This electronic message may contain information that is confidential and/or legally privileged. It is intended only for the use of the individual(s) and entity(s)  named as recipients in the message. If you are not an intended recipient of the message, please notify the sender immediately,  delete the material from any computer, do not deliver, distribute, or copy this message, and do not disclose its contents or take action in reliance on the information it contains. Thank you."     ----- Original Message ----- From: Paul Costello To: WEDI SNIP Transactions Workgroup List Sent: Friday, March 07, 2003 11:13 AM Subject: Accept v. Process Standard Transactions Group, I have a question regarding "accepting" and standard transaction and "processing" a standard transaction. I was under the impression that in order to meet the HIPAA guidelines, a covered entity only had to be able to accept a standard transaction, but not necessarily process with all the data elements that come in.  Also, my understanding was that from a payer's perspective, HIPAA does not mandate that payers completely change their core business processes in order to process a standard transaction.  Am I off-base? For example, if a payer only processes claims that come in at the line-level and it receives claims at the claim-level, is the payer still obligated to pay the claim-level claims, or can it just accept the claim-level claim (meeting HIPAA requirements) but not pay? Another example would be when anesthesia charges are billed on a claim, certain health plans currently require the surgical CPT code rather than the anesthesia CPT code.  If a provider, post October 16, 2003, sends an anesthesia CPT code, payers have to accept the claim with the anesthesia codes (understood), but do they have to pay?  Can they say that their systems only process using surgical CPT codes, so in order to get paid, providers must send anesthesia charges using surgical CPT codes? Wouldn't these two examples be instances where "companion guides" might be used? Any insight is appreciated. Thanks, Paul --- 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