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Jan,
I agree with your logic. We differ in how an
"adjutication system" is defined.
To my mind, an "adjudication system" is what applies business
logic to a transaction (i.e, the whole back end -- everything past the syntax
checkers). The result of that logic will be a business response of some
nature. This could be a chain of filters, rejecting those that don't pass
muster, and passing on the survivers to the next level of detail.
This is a good justification for keeping the syntax and IG
compliance checkers separate from the business logic -- to keep a
"non-complient" rejection totally separate from a "bunk" rejection. For
that reason, I would tend to want to keep the "we don't do ..." responses on the
business side rather than the syntax side.
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: Monday, March 10, 2003 01:24
PM
Subject: Re: Accept v. Process Standard
Transactions
Doug,
I think I must respectfully disagree with your statement that 'accepting
the claim means entering it into the adjudication system.' Let me know
if you disagree, but here is my logic:
A payer's "business system" usually begins long before a claim hits the
adjudication system, ergo, their front-end edits processes. Payers have the
right to apply business decisions in front-end edits. For example, a
payer who does not process dental benefits, might receive a perfectly HIPAA
compliant dental claim. It is my understanding that payers has the
option of rejecting the claim through their front-end edits process with the
message of 'we don't do these benefits'. The payer would also have
the option to accept the dental claim into their adjudication system and then
to deny it on the back side through an 835 'we don't do dental'. In both
cases, the outcome is the same (the provider receives no dollars) but the
reason is within the HIPAA model: the claim is rejected/denied for business
reasons, not for format reasons.
More Examples: Payers can reject if a provider submits a claim in an
incorrect format meaning the payer wants their home health claims in an
institutional format and the provider submits a HIPAA compliant professional
format. HIPAA does not dictate WHICH claim format payers must use for specific
services. Payers can reject/deny for things like 'subscriber not found',
'provider not found' and a host of this-claim-does-not-make-sense,
this-claim-does-not-comply-with-our-contract (assuming the contract is HIPAA
compliant: e.g. the payer is not requesting local codes) or
we-don't-do-that-business issues
The long and short of it is accepting a HIPAA compliant transaction does
not defacto mean that it gets into a payers adjudication system. It does
mean the payer can't reject/deny it for format reasons. Assuming the
format is correct, the payer must reject/deny for business reasons.
Paul's question is very critical from an operations/legal
perspective. It is a new way of thinking about how to handle
transactions. The challenge to the operational folks is how to maintain their
business needs and not cross the HIPAA line. Everyone is working this
out for themselves. While the outcome might be the same (the claim is
rejected/denied), the WAY its handled can make all the difference from a legal
perspective. Here at UHIN in our Standards Committee we've had many
discussions about the fine line between 'accepting' a transaction because it
is HIPAA compliants, and 'rejecting/denying' a transaction because it is bunk,
from a business perspective. People are getting more comfortable with
where this line is but it takes time and a lot of thought.
Jan Root
UHIN
Doug Webb wrote:
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 -----
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
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