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RE: interpretation of situational stuff!
Chandra,
Your provider did populate Related Causes, one of CLM11-1, 2 or 3 with "AA",
correct? That one IS very confusing, as it states that CLM11-4 (Auto
Accident: State) would then be "Required". CLM11-5 (Auto Accident:
Country) is "Required" if the Accident occurred out of the US. (They sound
mutually exclusive, right????). The Institutional is even more confusing on
that one. CLM11-5 is "Required" IF CLM11-4 is present. A Paradox?? I
think DSMO is doing away with the CLM11 Composite in the 837I as Related
Causes can be conveyed as an Occurrence Code.
If they do not have the information there, then they are likely not
compliant, .... would be my interpretation. I have not had to deal with
that one yet personally.
How you handle it, with a Rule or ignore it, depends on if your system
requires that information to adjudicate the claim or not and how you
store/communicate deny's, pends or disallows etc. If you handle that sort
of thing right out of translation or through another internal process. Does
it matter to your system?
Technically, I guess, you could reject the transaction and ask them to
resubmit. Have you asked your provider about it? How is it otherwise
conveyed that the accident indeed took place out of the country?
That is "fine tooth" implementation, however, you will likely run into many,
many interpretation issues of that sort. Too, they are working on ironing
out many of the "bugs" in the IGs.
Ah.. HIPAA.
Mary
-----Original Message-----
From: Chandra Damera [mailto:
Sent: Wednesday, October 17, 2001 2:25 PM
To:
Subject: [EDI-L] interpretation of situational stuff!
Hi all,
How do I interpret some of the situational stuff
within the IG?!
Example on the 837P(Pg.178), CLM11-5 says...
"Required if the automobile accident occured out of
the US to identify the country in which the accident
occurred."
Now for instance, there is a claim that I receive from
the provider on which CLM11-5 is blank though it is an
accident claim occured out of US.
Do I care to code this as a rule within my(payer)
system?! If yes, How do I identify this as a rule to
be coded within my system(Payer side) to reject the
claim?! There are ample amount of such situations
within the IG and I am wondering if it is left to the
providers' discretion to populate this element?!
Regards
Damera.
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