Jonathan, I respectfully disagree. The principal reason for the HIPAA rule is to make claims transactions more consistent. Providers have to bill payers based on the payer's payment policies (keeping within the HIPAA guidelines), and these policies differ. If we require providers to bill each payer differently when the service code and other basics are the same but the situational elements needed differ between payers, then we have fully defeated the reason for HIPAA.
The argument against your approach is further supported when considering the need to bill multiple payers for a claim (Coordination of Benefits or COB). In these cases, your approach would require the use of the COB option that requires the provider to bill each payer individually, and the option where payers pass claims on to the next payer could not be accomplished. It makes sense to me that providers should develop their claims submission systems to support all payer needs and that payers accept claims regardless of what data is in elements that they do not need. Kepa, in an earlier message, cited a segment from the IGs that providres should send the data if the situation applies. This can be interpreted multiple ways, but if the situation applies to one payer in the chain, then I feel it applies to the claim. Extending this argument, rather than requiring providers to determine which payers are in the chain, wouldn't it be more practical for payers to ignore any data that they do not need so that providers can bill individual services codes in a way that all payers who pay for that service code will accept? Don't confuse this with Uniform Billing where payers would agree to accept claims for services using the same service code and form (transaction type), because HIPAA does not yet dictate policy and the payer community is too involved in meeting HIPAA compliancy to be able to consider this. Walt -----Original Message----- From: Jonathan Allen [mailto:[EMAIL PROTECTED] Sent: Thursday, March 27, 2003 4:19 AM To: WEDI SNIP Transactions Workgroup List Cc: [EMAIL PROTECTED] Subject: Re: Situational segments/elements and payer-specific edits Dave Sell asked: > I'd like to know if any receivers will reject claims that have unneeded > Situational segments or elements. They certainly should. Two principle reasons: a. the old chestnut of HIPAA compliance - sending unneeded situational data would make a transaction non-compliant and both the sender and receiver in breach of the rules (and so liable for fines if caught) b. contractual and liability - if a receiver is not expecting certain data items, then they won't have mapped it to anywhere in their in-bound database or file format, which means that the data will effectively get dropped. Their application is therefore unaware that the unneeded data was sent and may accept, process, adjudicate a claim on the basis of only the data it receives. Subsequently, the claimant contests the adjudication on the basis of the unneeded but silently dropped (thus looking like accepted) data which they thought out to have been taken into consideration Jonathan ---------------------------------------------------------------------------- -- Jonathan Allen | [EMAIL PROTECTED] | Voice: 01404-823670 Barum Computer Consultants | | Fax: 01404-823671 ---------------------------------------------------------------------------- -- --- 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. 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