I agree. Not only can there be situational data that should not be sent, there can be situational data that is supposed to be sent that I, as a payer, do not care about. In either case, I would drop it out of the record used for actual processing. Rejecting a transaction because such data is present seems contrary to the concept of Administrative Simplification as I understand it.
________________________________ "And the saga continues..." David Bass DHS, Office of HIPAA Compliance Phone: (916) 255-5282 Fax: (916) 255-5271 -----Original Message----- From: Robert C. Pozniak [mailto:[EMAIL PROTECTED] Sent: Thursday, March 27, 2003 7:39 AM To: WEDI SNIP Transactions Workgroup List Cc: WEDI SNIP Transactions Workgroup List Subject: Re: Situational segments/elements and payer-specific edits Well Dave you've stirred up another contentious area so I'll offer another opinion. The final rule 169.925(a)(3) states "A health plan may not reject a standard transaction on the basis that it contains data elements not needed or used by the health plan (for example coordination of benefits information)." I've always believed Administrative Simplification was to standardize the electronic transactions and in the case of claims provide a methodology for providers to construct a single claim format with data content that any and all payers would be able to use to adjudicate the claim. The fact that one payer does not use certain data content should not allow for rejection of the claim, in my opinion. To operate otherwise just puts us back to requiring providers to submit a single format but with multiple data content requirements of various payers eliminating standardization. Are we to change from utilizing 482 different claim formats and data requirements to only using 4 claim formats (837 I,P,& D and NCPDP) but retain 482 different data content requirements. Just my opinion but I would appreciate hearing other's thoughts. Robert C. Pozniak NYS Department of Health HIPAA Practice Group "WEDI SNIP Transactions" <[EMAIL PROTECTED] To: "WEDI SNIP Transactions Workgroup List" thcoop.com> <[EMAIL PROTECTED]> cc: 03/26/2003 12:51 PM Subject: Situational segments/elements and payer-specific Please respond to "WEDI edits SNIP Transactions" I have a general question about Situational segments and elements and a somewhat related question about payer-specific edits. My Situational question deals with 837 transactions but it could be applied to all transactions. I'd like to know if any receivers will reject claims that have unneeded Situational segments or elements. I have a couple of examples: Onset Date at Service Level (2400 loop) being the same as the Onset Date at Claim Level (2300 loop) CLIA Number submitted on non-Medicare/Medicaid claims I haven't found any explicit language saying unneeded Situational items cannot be sent, but it's clear that they "should not" be sent, leading to individual interpretation of the language to determine if it's allowable when not needed. I'm asking because, as a repricer of claims, I receive claims from many sources (direct-submitting providers and clearinghouses) and then send those repriced claims on to payers. All inbound EDI transactions will be HIPAA compliant and I'll be inserting my HCP segments at the appropriate location within each claim and then sending those claims on to payers. When I receive claims with unneeded Situational segments or elements, I simply ignore the unneeded information and I'm hoping the payers I send to will do as well, which does seem to be the case in most I have spoken with. I'm trying to limit the number of claims that I originally accept from a sender, only to have those claims rejected by a receiver for some reason. As for my question about payer-specific edits; most of these submitters only identify the claim as our claim, rather than identifying the ultimate destination of the claim - the payer. I've been asked by the submitters what edits I want applied but the few edits I want may not include the payer-specific edits that a payer may want. Is it fair of me to ask these submitters to identify the payer of the claim and apply those specific edits according to their companion guides? Since I'm not the creator of the claim and the source of the data, I don't feel that I can apply many of these payer-specific edits. Thanks in advance for any advice. Dave Sell Sr. Programmer/Analyst The Alliance [EMAIL PROTECTED] --- 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. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. You are currently subscribed to wedi-transactions as: [EMAIL PROTECTED] To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org --- 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. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. You are currently subscribed to wedi-transactions as: [EMAIL PROTECTED] To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org --- 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. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. You are currently subscribed to wedi-transactions as: [EMAIL PROTECTED] To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org
