Linda, I will take a stab at not answering your question. :-)
What is a transaction? There are at least two views: - The ASC X12 837 "transaction set" is the transaction adopted by the Secretary as the standard under HIPAA. If there are any defects in the 837, the entire 837 transaction set is to be rejected, regardless of how many claims it contains. Some are taking this "heroic" position. In fact, the 997 acknowledgment can either accept or reject an entire transaction set at a time. That is the only "granularity" of the 997. - The health care claim is the standard adopted by the Secretary, and the ASC X12 837 is the standard electronic vehicle to convey the standard claim. If there are any defects in the claim, each claim can be independently accepted or rejected, even if they happen to be inside the same electronic 837 envelope. Since the 997 cannot address this finer granularity, other transactions such as the 824, 277, or 835 must be used to communicate such claim by claim rejections. Of course, if the 837 transaction set is syntactically incorrect, the whole thing gets rejected with a 997. Today, using the NSF or UB92, a provider will be put in "production" by a CMS contractor as long as they have 5% or less "bad claims" in their EDI files. Some clearinghouses target this same 5% error rate as acceptable, and provide incentives to keep the error rate below 2%. But everybody recognizes that achieving a 0% error rate is unlikely, even with today's somewhat loosely defined NSF and UB92 requirements. So, my prediction is that if a payer takes the "heroic" position of saying the HIPAA X12 837 transaction sets must be perfect or they get rejected, the providers will find out soon enough (on the very first rejected 837!) and then they will change their translator to produce a single claim per 837, so the payer can reject a single claim without affecting other claims. Then the provider will turn the rejected claim around, print it on paper, and mail it to the payer. This will be specially important for clearinghouses, since you don't want one bad claim from a provider causing massive rejections to claims from other providers. The end result will be a waste of EDI translator resources at both ends, lots of paper, and lots of cost. But it will work, pretty much like it works today. My advice is that, as an industry, we should agree on a path to improving these transactions. Initially, given all the new requirements in the 837 we should agree to a relatively low success rate as being "good enough". For instance, if an 837 has 75% good claims inside, the entire 837 should be acceptable, and the 25% bad claims should be rejected individually or corrected by the payer. If the 837 has more than 25% bad claims, the entire 837 should be sent back to the provider until they do their homework a little better. As time goes by, the bar should be gradually raised. For instance by 5-10% every 6 months, until we get to a 95% acceptance rate. Then, perhaps the bar should be raised a little more, to 97-98% acceptance rate. What are the right numbers? Is 75% the starting point? How much to raise the bar and when? These are the sorts of decisions that are best left to an industry consensus such as WEDI SNIP. There is probably support in the law for such a thing. I am not a lawyer, but it seems like a goal of 95% compliance is in line with a "reasonable" effort to comply with the law, and I don't think a judge would penalize somebody that is making a reasonable compliance effort. But what do I know? So, as a receiver of the transaction, you can take the heroic stance and become the HIPAA Cerberus (mythological multi headed dog guarding the gate) or you can take a more pragmatic approach and take better advantage of the benefits that administrative simplification offers today. As time goes by, the situation will improve. In the mean time, this email is a call for action. The SNIP leadership ought to look into this issue and make some recommendations. Soon. Just my opinion. Kepa Zubeldia Claredi On Thursday 13 March 2003 10:40 am, Linda Young wrote: > I would really appreciate your help on this very basic question. > > As part of HIPAA compliance I understand that we must send compliant > outbound EDI transactions. My question is, are we supposed to reject > inbound transactions that are not HIPAA compliant? Can anyone point me to > a section in the final rule or federal register (or any HIPAA official > document or IG) that states that we should reject inbound transactions that are > not HIPAA compliant? > > Thanks > > Linda --- 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. 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