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William,
I think we're barking up the same tree here.
The critical implication of TCS "Accept ant promptly process"
is that if a transaction meets the syntax rules, the receiver has to
swallow it and do something appropriate with it in a timely
fashion.
Now, what does "promptly" mean? I know that other
methods such as DDE can't offer an incentive, so the response time for standard
transactions would seem to have to be at least as fast as any DDE
alternative. I also know that it doesn't reflect the time to final
adjudication, which, if regulated at all, is covered by regulations totally
outside the realm of HIPAA.
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]
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----- Original Message -----
Sent: Saturday, March 08, 2003 09:38
AM
Subject: Re: Accept v. Process Standard
Transactions
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
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