Healthcare Administrative Technology Association (HATA)’s

X12 277CA STC12 Recommendations 

The Healthcare Administrative Technology Association (HATA) is a non-profit trade association, founded in 2014, to provide a forum for the PMS industry and other affiliated stakeholders.  The association serves as the representative voice to advocate and influence key stakeholders and government representatives on PMS Vendor issues.  HATA wishes to thank athenahealth for its contribution and support in the development of this recommendation. 

HATA Technology Association (HATA) and its partner vendors support and reinforce the business need to:

  1. Retain the Ability to Convey Additional Specific, Detailed Payer Messaging in the 277CA with standardized claim category, status and entity codification to the highest specification;
  2. Develop and Publish Industry Collaborative 277CA Messaging Guidelines to strengthen the codification and payer additional messaging of the common use cases to restrain potential misuses. 

HATA and its partner vendors would welcome the opportunity to work with X12 in the development of Industry Collaborative 277CA best practice codification and messaging guidelines and/or provide any additional background on the impact of the 277CA on practice management systems and their provider clients. 

I.        Retain Ability to Convey Additional Specific, Detailed Payer Messaging in the 277CA

        HATA encourages payers to provide messaging on the 277 Claim Acknowledgments that:

  •  Contain standardized claim status codification to the highest specification
  •  Offer more specific, detailed, simplified messaging that consists of user friendly  terms so providers can understand why the claim was rejected, and
  •  Provide the next step in resolution, similar to what providers are accessing from  payer web sites to allow front end correction/action on an identified claim-specific  issue.

Business Need

  • Receiving too much information from payers is not a known provider complaint. 
  • Sending providers to portals for additional information that can be conveyed on the claim acknowledgement is inefficient and add unnecessary steps to workflow. 
  • Keeping providers within their familiarized workflow is more efficient and preferred.
  • Providing next step resolution instruction allows for:
  • quicker resolution and resubmission of the claim issue; and the
  • creation of value-add solutions to support increased automation within the workflow, with the caveat:
    • Receiving the most precise claim statuses which allow for the accurate routing of rejection message is of upmost importance.
    • Receiving conflicting or non-specific claim status codes and messages negatively affects accurate routing and increases manual work and call volume.
II.      Develop and Publish Industry Collaborative 277CA Messaging Guidelines

We recommend and would like to participate in the development of Industry 277CA codification and messaging best practices to encourage codification to the highest specificity.  As a starting point to “best practices,” we recommend the following guidelines for payer usage of an additional clarifying messaging when codification is reported to the highest specificity. 

  • If the most precise code combinations available are still insufficient to communicate the required information to the provider (as a temporary measure until more/better codes are requested.)
  • When it is necessary or reasonable to provide supplemental context information to the status code (and only when the addition of STC12 content does not change the nature of the status code itself).
  • When the relevant information to be communicated is variable and thus cannot be codified, such as a prior claim id causing a duplicate rejection, or the amount of units allowed for a given service which has been exceeded.
  • Method of Last Resort:  Provide links out to additional supporting detail/rules, similar to claims editing engines when needed.

 

277CA Workflow Examples

Below is a simplified mockup of one partner vendor’s system view where the STC12 message is displayed  to the user alongside the standard rejection message.

For more information, see "Use Cases:  Business needs for reinstating the STC12 in the 277CA 7030 transaction" discussion paper submitted to X12 Claim Committee by athenahealth and Optum, 1/26/17.  

 

 

About HATA:  The Healthcare Administrative Technology Association (HATA) is a non-profit trade association, founded in 2014, to provide a forum for the PMS industry and other affiliated stakeholders.  The association serves as the representative voice to advocate and influence key stakeholders and government representatives on PMS Vendor issues.  We promote the success of the administrative dimension of healthcare and the vendors that provide healthcare administrative solutions. 

Our PMS Vendor members, who provide services to over 750,000 providers, include: AdvancedMD, AllMeds, Aprima, Azalea Health, Clinix, e-MDs, Greenway Health, HealthPac, Medinformatix, NextGen, Office Ally, Optum, PracticeAdmin.  Members stakeholders who connect with PMS Vendors, include:  ALC Consulting, Inc., Alpha II, Availity, CallPointe, ClaimRemedi, eProvider Solutions, Find-A-Code, GeBBS, Healthcare EDI Partners, Inc., InMediata, InstaMed, PaySpan, PracticeInsight, TriZetto Provider Solutions, WorkCompEDI , Zelis Payment Solutions.  Members associations who are the provider users of PMS solutions, include: AMA, AMBA, MGMA and PAHCOM