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Clarification:
"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?"
FYI: the 835 transaction is NOT a
response transaction to the 837/NCPDP or any other claim format.
It is a payment/remittance advice transaction.
The rest of the answer
is within your bullets:
"... 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." --- It is required by HIPAA that
health plans send and receive HIPAA mandated transactions--NO Choices for
payors. The question is ... IS the Provider ready to accept
the 835? The payor can still generate the EOBs on paper through the
current process but, in the case of the 20 providers receiving electronic
today, the payor is mandated to send those providers the 835. Only the
provider has the choice as to which electronic transaction is being
conducted.
hope this
helps.
Ruth Tucci-Kaufhold
HIPAA Systems
Analyst
Health Information Management
UNISYS Corporation
4050 Innslake Drive
Suite
202
Glen Allen, VA 23060
(804) 346-1138
(804) 935-1647
(fax)
N246-1138
[EMAIL PROTECTED]
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
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