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Subject: Re: TP EDI Enabled ?

When I pointed out the need for unsolicited transmissions in the HIPAA
world, Peter D. Pruyne responded that "Many insurers have claim
acceptance done through clearinghouses, and therefore might not want (or
perhaps even have) direct destination information to be published."

That's true enough, where the insurer (payer or health plan) prefers to
use the value-added benefits (whatever those might be) of a VAN-like
clearinghouse, even when standard X12 transactions are being submitted
by a provider.  A clearinghouse's attractiveness becomes problematical
when the cost can't be fobbed onto the provider;  see 45 CFR 162.925(5)
(Additional requirements for health plans):

   A health plan that ... requires [a provider] to use a health care
   clearinghouse to receive, process, or transmit a standard
   transaction may not charge fees or costs in excess of the fees
   or costs for normal telecommunications that the [provider] incurs
   when it directly transmits, or receives, a standard transaction
   to, or from, a health plan.

That looks to me that if a provider is ready and willing to send claims
via EDIINT (EDI over the Internet), or soon as payloads in ebXML TR&P
messages, then the insurer will have to make itself capable of receiving
them, or pay all the costs of having the intermediary (hub, spoke,
e-business switch, clearinghouse, or what ever term du jour is used)
relay the standard transactions.

William J. Kammerer
4950 Blazer Memorial Pkwy.
Dublin, OH USA 43017-3305
+1 614 791-1600

Visit FORESIGHT Corp. at http://www.foresightcorp.com/
"Commerce for a New World"

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