Payer 835 Response to Provider 837 Scenario Question

[Gregus, Gary]

Title: Message

To TWG List:   I'm a (somewhat experienced) HIPAA EDI consultant on assignment for the ANSI 835 transaction at a MCO Health Plan in Philadelphia. PA.   The HIPAA Project Manager and I have a difference of opinion concerning the interpretation of the HIPPA regulations with regard to a payers responsibility or requirement in reference to receiving an electronic HIPAA compliant ANSI 837 claims submission file from one (or many) of their providers.   Your assistance to resolve this difference of opinion related to HIPAA regulations interpretation would be greatly appreciated.   Some scenario background defining the MCO Health Plan's current (EDI) processing environment: The MCO Health Plan's business is primarily Medicaid They receive electronic ANSI 837 version 3041 claims submission files from at least 20 providers today All inbound claims files are received via an FTP type transmission through a clearinghouse (WebMD) All associated electronic remittance advice (ERA) records are generated out of their claims adjudication system in a proprietary format and transmitted to an outside vendor who is contracted to print EOBs and checks and mail them to the appropriate providers.   No "true" EDI ERA is performed with any providers today. To make this scenario a little more interesting, a handful of providers receive the proprietary ERA files via a system generated email (file) attachment process   For HIPAA, the MCO Health Plan is not looking for their clearinghouse (WebMD) to convert proprietary / ANSI files for them The MCO Health Plan's ANSI 835 transaction project solution approach is to leave the existing proprietary files process (to the vendor for printing of EOBs and checks for the providers) alone and simply add a new standard EDI process to generate the ANSI 835 version 4010 electronic remittance advice files to be sent to providers via WebMD  The MCO Health Plan will look to eventually eliminate the paper EOBs (by provider) once the providers are comfortable with processing the new HIPAA ANSI 835 files received   The issue / question is:     Come October 16, 2003 when these 20 providers upgrade their systems and begin sending their HIPAA compliant ANSI 837 (version 4010) claims submission files to the MCO Health Plan via the WebMD EDI communications connection, will the MCO Health Plan be "required" to return response ANSI 835 transaction files  OR  do they only have to supply the HIPAA ANSI 835 response files based upon individual provider request?      An answer to this question would be greatly appreciated along with any excerpts from the HIPAA regs, CFR, etc. which supports this answer.   I have reviewed the Federal Register (45 CFR Parts 160 and 162) and did not see specific language, comments /  responses, or examples pertaining to this issue / question.   Thank you all so much in advance for your time and effort in responding.   Take care.                                                             Gary Gregus  (215-863-5137)                                                          HIPAA / EDI Transactions Consultant                             --- 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 CONFIDENTIALITY NOTICE: This electronic mail may contain information that is privileged, confidential, and/or otherwise protected from disclosure to anyone other than its intended recipient(s). Any dissemination or use of this electronic mail or its contents by persons other than the intended recipient(s) is strictly prohibited. If you have received this communication in error, please notify the sender immediately by reply e-mail so that we may correct our internal records. Please then delete the original message. Thank you.