Doug, I'll admit I really don't know the words folks in the bowels of Healthcare IT use for describing various stages in the life of an electronic transaction. All I know about the terms is how they're used in the TCS regulation. "Accept" seems to come before "process," though: � 162.925(c)(1) says health plans must "ACCEPT and promptly PROCESS any standard transaction that contains codes that are valid..." The order seems clear.
A snippet from the preamble is consistent with that interpretation: "For example, a health plan cannot refuse to ACCEPT a claim from a health care provider because the health care provider electronically submits the standard transaction. However, the health plan is not required to pay the claim merely because the health care provider submitted it in standard format, if other business reasons exist for denying the claim (for example, the service for which the claim is being submitted is not covered)." (65 FR 50315) Further: "For each standard transaction there are situational data elements that are both relevant to the particular transaction and necessary to PROCESS it." (65 FR 50322) Again, we shouldn't get hung up on these terms. A plan always has to ACCEPT a standard transaction (from someone it has reason to believe is a legitimate provider, clearinghouse, or another plan). And ACCEPTance necessarily implies taking the interchange through the translator, if only so the negative or positive technical TA1 and 997 acknowledgements can be generated. Obviously, by this time, the (syntactically valid) transaction(s) have been mapped and are ready to be PROCESSed. It doesn't mean the claims are going to be paid - the plan still probably doesn't even know if the subscriber is one of theirs! Or that all situational data is present (e.g., subscriber's birth-date is present if the subscriber is the patient). Now the plan can start PROCESSing. I imagine this elusive "ADJUDICATE" is part of PROCESSing, coming after the front-end edits, which I suppose are the first part of PROCESSing. But the EDI has long been ACCEPTed and translated into internal database tables or flat files, upon which PROCESSing takes place. Raw EDI data itself is never PROCESSed itself, of course. 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: Friday, 07 March, 2003 03:42 PM Subject: Re: Accept v. Process Standard Transactions 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] ----- Original Message ----- From: "Paul Costello" <[EMAIL PROTECTED]> To: "WEDI SNIP Transactions Workgroup List" <[EMAIL PROTECTED]> Sent: Friday, 07 March, 2003 12:13 PM 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. 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