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Mary,
Your
points are well taken.
Please
let me clear up one thing, though.
The
only "HIPAA guide" is the May 2000 4010 guide (for those covered entities who
wish to be compliant today) and the combination of the May 2000 4010 guide and
the October 2002 4010-A1 (Addenda) guide for all covered entities as of
10/16/2003.
The
4050 guides are not HIPAA guides. They are the next evolution in the X12
publication process. As such they frequently contain useful and
informative clarifications of the intent of the workgroup (as in this
case). So, do you have to follow the 4050 guides? No. Can they
provide useful clarifications, in some cases, about doubtful areas?
Yes.
Hope
this helps.
Tom Drinkard
EDIT, Inc.
(678) 795-1251 (voice)
(775) 458-6117 (fax)
Tom,
I did look into the 4050 Guide and you indeed
are correct, although I have never had issues with Translating that type of
construct as I key in on the HL flags. But that is for Inbound
Maps, so they will work either way. My biggest concern here is the Outbound maps I
have built. I may
have to restructure them although Claims for both Subscriber and Patient are
not common, it is those situations that will make trouble somewhere down the
line... they are the ones I look for in testing my
maps.
It
is a shame that those of us 'techies' in the trenches building the Maps
and Translators do not have time to be more involved in the
workgroups. I would give my eye-teeth for that kind of time.
(Keeping up with the often important and informative information on this
Listserve is too a challenge. I am sure I am not alone in that
one).
The
IG that was adopted for HIPAA and the one I have been Mapping from I have read
many times over and used as Bible.. particularly the examples. I
guess with the future in mind, I should refer to the 4050 Guide also *sigh*,
although the fact that it is "Draft" made me leary of doing so. It
is difficult enough interpolating the 4010 with the Addenda, ...which I refuse
to kill trees for and print.
I do
appreciate your clearing this up for me... although I am struggling with the
fact that 4010 is the adopted version, yet we are to be using a
draft version as a HIPAA guide?
Respectfully,
Mary Burkinshaw
Axiom Systems, Inc.
-----Original
Message-----
From: Tom Drinkard
[mailto:[EMAIL PROTECTED]
Sent: Wednesday, September
17, 2003 8:56 PM
To: 'Mary Burkinshaw'; 'WEDI SNIP Transactions
Workgroup List'
Subject: RE: 837 Looping
question
Mary,
The bottom line in this discussion is SBR02.
Either it has a value of 18 (Self) or it must not be
used.
The actual note in the Professional Claim guide
says:
"Required when the subscriber is the same person as the patient. If
the subscriber is not the same
person as the patient, do not use this element."
You can't have it both ways. Therefore, you must repeat the
2000B loop in order to have claims for the subscriber and one or more
patients.
This topic has been discussed at length in the Health Care Claims
workgroup at X12N. Please see the draft copies of the 4050 guides for
a clearer presentation of the intent of the workgroup.
Tom Drinkard
EDIT,
Inc.
Co-Chair X12N/TG2/WG2 (Health Care
Claims)
(678) 795-1251 (voice)
(775) 458-6117 (fax)
Tom,
My take on it is different, and I may be wrong,
but it would seem that the HL04 would indicate whether or not this
Subscriber has Dependents, but the Subscriber him/her self "could" be a
Patient within the same grouping.
I do not see anywhere in the guide that says the
Subscriber needs to be repeated in the case where there are also
Dependents.
Subcriber1(2000B,2010BA,2010BB)
HL*3*2*22*1
< this "1" says this hierarchical level has a Dep.
SBR*P*18*.... < the "18" is required because this
Subscriber is the Patient.
CLM
(2300)
for this Claim.
Services (2400)
......
Patient 1(2000C,2010CA) .. Subscriber1
Dependent
HL*4*3*23*0 < this Hierarchy points to the
Subscriber1 as its parent.
PAT*01*... < Spouse of
Subscriber1
CLM
Services
Patient 2 (2000C,2010CA) .. Subscriber1
Dependent
HL*5*3*23*0 < again, points to
Subscriber1
PAT*19*... < Child of
Subscriber1
CLM
.Subscriber2.......
The example on the bottom of page 38 - 40 of the 837 X098
(Professional) does show the above construct gave me that impression
as it depicts Subscriber #4 with both a Claim AND a Dependent with a
Claim. Please let me know if I am reading that
wrong.
I thought I was pretty comfortable with HL Parent/Child constructs
in having done a number of 856s in Retail EDI.
Respectfully,
Mary Burkinshaw
Axiom Systems, Inc.
Actually neither option is correct. You cannot mix a
subscriber's with a patient's claims, unless you repeat the subscriber
loop.
Given this premise, then if you modify option one by copying line
one between lines three and four you would have a valid transaction
set. The end result would be as follows:
OPTION1
1.
Subcriber1(2000B,2010BA,2010BB)
2. Clm(2300)
3.
Service(2400)
3.5.Subcriber1(2000B,2010BA,2010BB)
4. Patient 1(2000C,2010CA)
5. Claim
6. Service
7. Service
8. Patient
2
9. Claim
10.
Service
11. Claim
12. Service
13. Service
14.Subscriber2.......
Tom Drinkard
EDIT,
Inc.
(678) 795-1251
(voice)
(775) 458-6117
(fax)
For 837P, I have a question regarding
mutiple claims for one patient. For example in a transaction,
Subscriber1 has two dependents. Subscriber1 has one claim, one
claim for dependent Patient1, two claims for dependent Patient2.
Which is a right approach - option1 or
option2(Notice the difference at line 11). Or, am I thinking in a
wrong track, as mutiple claim lines for one patient under same
Provider in same transaction set will not occur(only mutiple
service lines). Thanks in advance.
OPTION1
1. Subcriber1(2000B,2010BA,2010BB)
2.
Clm(2300)
3.
Service(2400)
4. Patient
1(2000C,2010CA)
5.
Claim
6.
Service
7.
Service
8. Patient
2
9.
Claim
10.
Service
11. Claim
12.
Service
13.
Service
14.Subscriber2.......
OPTION2
1. Subcriber1
2.
Clm
3.
Service
4. Patient
1
5.
Claim
6.
Service
7.
Service
8. Patient
2
9.
Claim
10.
Service
11. Patient 2
12. Claim
13.
Service
14.
Service
15.Subscriber2.......
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