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RE: HIPAA x12 837 document vs. Proprietary formats
Bill, as my good friend William Kammerer identified, whether you can use a
proprietary format or not depends on where you are in the flow of a claim
from the provider to the payer (health plan).
HIPAA legislation and regulations allow for and recognize that either a
provider or a health plan or both may choose to outsource the function of
creating or receiving and processing a HIPAA standard claim transaction by
defining clearinghouses and what they may do.
My suggestion to you would be to map out the flow of the claim data from the
provider to the health plan, determine where your company is and what its
role in the overall claim processing is, as well as your TPA's.
All that's required under HIPAA is for the claim transaction to be in the
standard format with the standard data for a nanosecond. This means that a
single clearinghouse can be both a business associate to a provider and the
intended health plan. The questions to ask then would be your company's role
and for which type of entity(ies) is it providing services. This should help
you to determine whether you may under the HIPAA rules, exchange a
proprietary format with the TPA. My initial opinion is that since the TPA is
the business associate of the health plan, it has already received the HIPAA
claim either directly from the provider in the standard format or via a
clearinghouse in a non-standard format. Once the claim is in the TPA's
possession, it can send it elsewhere for further processing in any format it
selects as long as both parties agree and are able to support that format.
The relative power of these two entities (the TPA and the re-pricer) will
determine whose rules will apply.
Rachel
Rachel Foerster
Rachel Foerster & Associates, Ltd.
Voice: 847-872-8070
email: <mailto:
-----Original Message-----
From: Bill Ames [mailto:
Sent: Monday, December 01, 2003 11:27 PM
To: 'David Frenkel';
Subject: RE: [EDI-L] HIPAA x12 837 document vs. Proprietary formats
Thanks for all the feedback.
David,
I'm defiantly not avoiding creating an 837. I currently use EDIFECS and
Claredi for all my HIPAA compliancy checks and all my current maps are
already complete for our TPAs. I just happened to run into another
client that wants to receive a proprietary format. Since my client is
the Payer (TPA for self insured companies) which is sending out the
claims to be repriced, it was unclear to me if that was possible to do
under the HIPAA guidelines. I would most certainly like to tell them
they have to accept an 837 because that is what is required by HIPAA. I
would hate to have to implement all the HIPAA compliancy checks on a
non-standard file.
Bill
-----Original Message-----
From: David Frenkel [mailto:
Sent: Monday, December 01, 2003 7:51 PM
To:
Subject: RE: [EDI-L] HIPAA x12 837 document vs. Proprietary formats
Bill,
Why are you trying to avoid creating a HIPAA compliant 837? It would be
impossible to use any 3rd party HIPAA compliance tools and you make it
difficult to use the HIPAA implementation guides as well as any
companion guides.
Regards,
David Frenkel
612-237-1966
-----Original Message-----
From: Bill Ames [mailto:
Sent: Monday, December 01, 2003 3:21 PM
To:
Subject: [EDI-L] HIPAA x12 837 document vs. Proprietary formats
Currently all I am doing is ANSI x12 837 HIPAA compliant data
transaction for health claims. I have been recently asked the following
question which I'm really not sure on.
Can you send electronic claims in any other format besides the ANSI x12
837 with all the HIPAA checks? Meaning, can a company send for example
a proprietary flat file of claim data as long as it meets the same
situational data requirements as the 837? Granted it is more difficult
to do compliance checks on this data.
Also, if the answer is no, you can only send claims via the 837, where
do clearinghouses fall in. They have to have some proprietary data
format at some point correct? What if a clearinghouse is representing
both trading partners? Do they translate data file...to 837...back to
data file or just simply skip the 837 if they are confident that data is
HIPAA complaint?
I have looked on various government websites for this answer only to get
lost in the endless link clicking maze. If anyone has an exact link to
the answer of this question, I would be most grateful.
Regards,
Bill Ames
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