Group Minutes X12N TG2 WG3 Claim Payment Workgroup January 29, 2007 Denver, CO

Transcription

1 Group Minutes X12N TG2 WG3 Claim Payment Workgroup January 29, 2007 Denver, CO Chair(s) Name Company Term End Date Phone Pat Wijtyk Payformance Feb 2007 Ph: Fx: Payformance.com Debby Conklin Chesterfield Oct 2008 Ph: Fx: Debra Strickland e-emergence Oct 2008 Ph: Fx: Secretary(s) Name Company Term End Date Phone Debra Strickland e-emergence Oct 2008 Ph: Fx: Ph: Fx: Ph: Fx: Quorum Requirement Statement (please check one) This group enforces quorum requirements for group voting items. This group does not enforce quorum requirements for group voting items. X Work Products and Status x Health Care Claim Payment/Advice Meeting Notification Date: 1/29/2007 Place: Grays Peak Contact Person: Deb Strickland Agenda: Monday 1/29/2007 House keeping New member introductions Voting nomination announcement Pat running nominations close EOD today. Who will be attending other meetings this week? Review of the Eligibility issue determine if we meet during that time 1-4 today. Review of the notes consolidation project work. Review of what is covered in the NUBC HIPAA forum on Wednesday. - We have some a DM for the RAS segment 1 04/06/2007

2 We have HIR s to talk about in the WG this week having to do with COB etc which we will talk about Tuesday Version of the guide It was moving forward in congress but with the change of congress etc this is now dead no one is interesting in taking this on so Don is looking at alternatives go out for public comment NPRM to make a change we have to do a new version of the guide. There may be multiple NPRMs that have to occur. The new versions of the guide will be a larger issue for 837 as they get many more comments etc. We are in pretty good shape. What is happening with attachments This is not going to happen until approx Has been reviewed CMS etc. 269 We have finished the change log and finalized the documentation sent to WPC for publication. Will additional guides be added to the HIPAA transactions no there are not plans at this time. 269 has to be piloted and tested. Review of the Code committee results Review of the WEDI code sub-committee Doug Discussion about payers who are not using the remarks codes Bob Poz Brought up a payer that had 700 internal codes and only using 19 CARC s and no Remarks. Mary RX for Pharmacy the LQ has to use this for reject codes. Providers really have no recourse if they are not getting the data they need. Providers have to revert back to or hang onto paper. Barb There is still a considerable amount of misuse of the group codes. Bob hearing that payers were lazy and did not map well, we then tried to require remarks codes for some reason codes, now we will try and consolidate the reason codes remarks codes. John states have CARC code groups payer and providers work together to work on the codes they use and how they use them. State workgroups have had good success. Barb the use of 96 that says Not covered, they were looking to add additional codes to explain that it is not part of the plan of benefits. So they know why it is not covered because of plan of benefits Pat has a WG that reviews these codes Kim does not feel that the new guides are moving we are requesting new codes etc but the payers are not interested Raphael Asked this WG to not grant an extension to Sept for the remarks codes requirement on the CARC codes. New SIGs at WEDI that we are involved in. Barb and Doug Code subgroup Deb and Barb financial SIG Pat and Barb Technical SIG 2 04/06/2007

3 Real time adjudication Pat gave over view of what the conference will cover etc Focus is 837 and 835 Can the current guides support this and are the payment remit comes back how legally binding is the response? 837 WG is going to talk about the Real time conference. Bob P Precertification of benefits is already in place and that is what would be used before the service. Had reviewed this concept of using the 835 as a real time transaction. There is also XML transactions etc. Take out redundant items in the 835 will cut down the transaction considerably. Rapheal Can t cut down the current guide would have to be a new guide for a specific new purpose. Barb Jones can the data be presented on the screen and not look like the 835 or 837. The real-time conference goal for day two is to review the activities of the speakers etc and formulate the plan going forward. Create a game plan and timeframe for moving forward. Rapheal wants to make sure that standards around the number of lines etc are considered. So that the payers can pay them. Kim their process if the claim cannot go through RT they send it to batch process and send that message back Is this for outpatient and inpatient services May not be when the patient is in front of you at the time. May do it at the end of the cycle. Bob P Would it be valuable to review the potential look of the real time remit. Brenda - Nominated Bob Poiesz because he wants to run for co-chair NPI open meeting Review the NPI as it relates to the 835. Review the various models 1) 1 PIN NPI 2) Multiple PIN NPI 3) 1 PIN ----Multiple NPI 4) Multiple PINs---Multiple NPI s State Medicaids are requiring providers to report Taxonomy codes. Medicaid Strongly suggested that the provider get one NPI and use taxonomy. They will get as many ERA s as they do today. Or they can sort the data by using the TS3 to get one ERA for one NPI Some providers are doing sorting by NPI and Patient number sorting internally. Taxonomy there is no place in the 835 to put this. Sumita Model 1 PIN and Multiple NPIs Is this going to happen Medicare has first 3 scenarios 3 04/06/2007

4 New providers will get an NPI and will be single PIN Stage 3 they will use the comb of PINs and NPIs They will get the combo by using taxonomy code Oscar codes etc % of their providers will be the first one There is a small percent that are models HCA Has applied for NPI like Medicare 3 PINs originally Humana map to one proprietary code Providers are enumerating like they have to for Medicare so the payers are going to get many more numbers then they had in the past. NY Medicaid - Multi ID s getting one NPI Working with the provider to make the situation one to one Multiple NPI only one provider IDs they will work to create IDs to match the number of NPI s Clearinghouse Don Enumerated with one NPI for all legacy ID s Received the remit and could not distribute to the correct mailbox. Provider John Many to Many Multiple PIN /Multiple NPI Does not understand why it is bad there are many to many that are relating one to one. Group clinics multi remit systems and now there is one that is tricky. Lori B when just the NPI is sent in on the claim Payer will not know with PIN this was supposed to crosswalk to. Rapheal Many too many not bad if the provider tells the payer about how they are enumerating in a clear manner. Doug providers are tying the NPI to the reimbursement system. Bob some multiple to multiple will be easy on the provider side. Pins are letters and NPI numbers If you are splitting the data that used to be in one PIN into two separate NPI s it gets hard to make that split. Account number is not unique among payers. Mayo- Already splitting the files many ways breaking apart the file but then tries to handle the PLB data. How are the payers going to put the data to explain the split. Humana Kim Break out each facility in the TS3 with a different NPI and sort the claims in there CMS information will be coming soon NY Medicaid will not be ready for NPI May 23 more likely To date only 7% have registered NPI s with them Not using NPI as the main ID They are requiring the providers to send old ID s. Payer if providers do not give NPI s to payers, Payers cannot use them to test and create accurate crosswalks. 4 04/06/2007

5 Carol Ask Raf is CMS aware of the situation and what did they say. Rapheal Providers helped to make the decision. Bob Poz Met with xxx and they also said they applauded them also and did not say what would happen. Carol Stats say 1% of claims are coming in with NPI and PIN Getting many of them from Medicare. How are people collecting NPI Providers have to contact the payer to communicate the NPI Sent out form to gather the NPI worked pretty well. 60% are collected and reported. They are not doing anything with the NPI s. John Washington state is collecting the NPI s via one source for the whole state. That is working out really well Doug dual use if the NPI comes in they will use it. Payer by payer when the payer says they are ready they are ready to go. Provider will come to the Siemens website to make sure they have the registration data accurate. United purchased software to do the rollup Carol requiring the confirmation for the NPI. So they can validate the data for registration, Mary RX only has one number so they can t do dual use now. Kim rolling up in their system so they can use the same identifier Bob just because the provider sends you an NPI they may not actually send in the claims that way. Pat After May 23 rd How will payers account for Atypical providers United not going to reject they will pay if they send in TIN. Not going to reject they will have a way to separate that data and make sure they go back and contact the provider. Will take longer to adjudicate. Carol Florida they are not going to allow any claim in electronically to come in without NPI. Lori bring them in deny the service if there is no NPI and there should have been. Gail Not able to contract with atypical providers that is why they do not expect these types of claims. Reject back to the submitter 835 will not go out the door without NPI if paper claim was sent paper claim with no NPI 835 will not be sent out. Co-chair Pat review the Payformance role and Deb Strickland s role with e-emergence. Motion to close the nominations second Jane Bryson Unanimous close nominations. BOB SYNOPSIS OF SITUATION: MEDICARE WILL CONTINUE TO USE OSCAR NUMBERS FOR COST REPORTS TR3 WILL ONLY REPORT ON NPI HOW WILL PROVIDERS BE ABLE TO APPLY TR3 AND COST REPORTS CMS RESPONSE: 5 04/06/2007

6 REPORTS WILL BE POSTED BY LEGACY NUMBER AND NPI SO THAT PROVIDERS CAN CROSSWALK BP OBSERVATION: TS3 AND TS2 WILL NOT BE USED BY MEDICARE POST NPI TS2 MAY NEED TO BE ELIMINATED IN THE NEXT GUIDE. TS3 WILL NEED TO BE RE-WRITTEN TO REMOVE REFERENCES TO MEDICARE COST REPORTS. CMS FOLLOW-UP CMS GETS MIXED MESSAGES FROM PROVIDERS AS TO USEFULNESS OF COST REPORT Review of HIR HIR 484 Title PLB03-2 Reference Identifier Description My question is, What is the industry standard for reporting the reference identification for an authorized return in the PLB03-2 data element? We use the 72 reason code, and then use the internal claim number from the CLP07 for the reference Identification *72> *. Is it standard to use the claim number as the reference identification or do more payers/providers use the patient account number from the CLP01 data element? Or is there another reference identification that is used? Response: Recommendation: The contents of PLB03-2 (or any related identification PLB element) depend upon the business situation. If the authorized return was the result of a letter to the provider that contained a financial control number that belongs in PLB03-2. If there is no financial tracking number on the payer correspondence to the provider then the WG recommends including a combination of CLP01 and CLP07 or use only one of these elements, if available. See the explanation of claim overpayment recoveries in the most current 835 implementation guide X221 - for additional explanation and guidance. See section (Claim Overpayment Recovery). Comments: Topic: HIR PLB03-1 Ref Identification Desc (3 of 4), Read 21 times Conf: 835 Implementation Guide From: Jim Whicker arjwhick@ihc.com Date: Friday, December 29, :49 AM I know it's a little late to weigh in - but - the PLB is intended to report provider level adjustments, and as such, are not intended to tie to any particular claim. I know it's a difficult process for providers at time - but when the lines between PROVIDER LEVEL adjustments and CLAIM LEVEL adjustments are blurred - it causes more confusion than it should. The patient control # is a claim level number, and putting it in the PLB perpetuates the notion that a provider needs to track the PLB amounts back to a particular patient account. I'd say the verbiage should discourage usage of patient control # in the PLB. Topic: I understand, but... (4 of 4), Read 14 times 6 04/06/2007

7 Conf: 835 Implementation Guide From: Bob Poiesz bobp@wpc-edi.com Date: Tuesday, January 02, :17 AM... there are specific situations where the claim control number is the id for the resulting adjustment, as assigned by the payer. We can not just ignore that usage, or require that it be changed. For instance, the situation described in the section referenced in the response. When the payer does a reversal and correction that results in a net lower payment but does not recoup the money immediately, the payer frequently uses the claim number as the control number for the receivable. While I personally believe that it is better for everybody to just take the money immediately, there are payers and providers that disagree and want to allow for things like 60 days for the provider to send a check. Technically, the ID is now the receivable ID and no longer the claim ID, but that level of differentiation is generally more confusing than helpful when trying to describe the way this business is to be handled. HIR 503 Title CAS PR Description I would like to verify if an insurance company is utilizing the 835 correctly. The following is a sample of the transactions we are receiving. CAS*OA*94* CAS*PR*2*899.98**3*10 Our issue above is the insurance is reporting a Patient Responsible (PR) amount of $ and $ The insurance states the $ is balanced out by Other Adjustment (OA) code 94 and the only amount the patient is responsible for is $ Is it compliant to utilize the PR and then the OA to off set an amount reported as PR? Response: DRAFT The OA group code cannot be used to offset a PR group code adjustment. Based upon the information provided the Workgroup cannot see any business reason for the offsetting dollar amounts. The Patient responsibility amount in the CLP05 must be accurately reflect the NET amount the patient owes the provider. full example of 835 CLP*604000*1*5633.2* *916.48*16*06292**1 NM1*QC*1*hhhhhhh*ccccccccc*S***MI*A0000 DTM*232* DTM*233* DTM*050* SVC*N4> *14.25*0*0250*3 CAS*CO*45*14.25 SVC*NU>0258*2*0**1 CAS*CO*45*2 SVC*NU>0270*109.85*0**6 CAS*CO*45* SVC*HC>93510*2940* *0481*1 CAS*OA*94* CAS*PR*2*899.98**3*10 CAS*CO*45* SVC*HC>93543*182*0*0481*1 7 04/06/2007

8 CAS*CO*45*182 SVC*HC>93545*206*0*0481*1 CAS*CO*45*206 SVC*HC>93555*321*0*0481*1 CAS*CO*45*321 SVC*HC>93556*321*0*0481*1 CAS*CO*45*321 SVC*HC>Q9950*144*.42*0636*2 CAS*CO*45* SVC*NU>0710*1375*0**250 CAS*CO*45*1375 SVC*NU>0990*6.5*0**1 CAS*PR*2*6.5 SVC*HC>J2250*11.6*0*0636*2 CAS*CO*45*11.6 If the secondary payer spits the claim, the total impact due to the primary payer s payment cannot exceed the impact if the claim had not been split Second question Can the secondary split the claim yes but it cannot create more of a deduction because of that split. Jim W. - If you split the claim split the claim level adjustment with it. RESPONSE: Please see HIR 455 for further information on how to report the primary payments to a secondary payer. Balancing rules apply regarding the impact each payer involved in the adjudication process. The preferred method of processing is an allocation of prior payers payment/adjustment to submitted charges or prior payers allowed charges. The secondary payer must account for the primary payer s payment, adjustments (CARC OA*23) and subsequently a tertiary payer must account for both the primary and secondary payments/adjustments. This results in an adjustment using Group Code OA CARC 23 at either the claim or service level as appropriate. Recommendation: Refer to section for claim splitting This is the presentation (and discussion time) on COB. 1. Traditional COB: NAIC guidelines require the secondary plan to pay the difference between the total allowable, i.e., the higher of the two, and the amount paid by the primary plan. The theory behind this model is that the secondary plan benefits greatly from a COB provision, it is fair to require secondary plans to make the covered whole with respect to allowable expenses. 8 04/06/2007

9 Self-Insured plans: Traditional COB plus a reserve: (NAIC) When a plan is secondary, it shall reduce its benefits so that the total benefits paid or provided by all plans during a claim determination period are not more than 100 percent of the total allowable expenses. The secondary plan shall calculate its savings by the amount that it paid as a secondary plan from the amount it would have paid had it been primary. These savings shall be recorded as a benefit reserve for the covered person and shall be used by the secondary plan to pay any allowable expenses, not otherwise paid, that are incurred by the covered person during the claim determination period. Reserve benefits are usually paid to the claimant. 2. Integration of Benefits: ( ) Allows the individual to receive as much in benefits as they would in the absence of other coverage, meaning that the secondary plan will only pay its benefits to the extent they exceed the benefits paid by the primary plan. The claimant gets the benefits provided by the better of the two plans. In June 2005 CARC 23 was changed to Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments. 1. Traditional COB Charge $2,500 Primary Plan Payment $1,920 Primary Plan Allowable: $2,400 Secondary Plan Benefit in absence of other coverage: $1,555 Secondary Plan Allowable: $2,200 COB Calculation: Total allowable for the claim is $2,400 Balance that remains after primary payment is $480 Since $480 is less than the amount that the secondary plan would pay if there was no other coverage, the secondary plan pays $480. Impact of the primary payment on the secondary carrier is $2020: $100 contractual write-off $1920 payment SVC*HC:59510*2500*480~ CAS*OA*23*2020~ 2. Statutes that prohibit consideration of primary contractual rates: Charge $2, /06/2007

10 Primary Plan Payment $1,920 Primary Plan Allowable: $2,400 Secondary Plan Benefit in absence of other coverage: $1,555 Secondary Plan Allowable: $2,200 COB Calculation: Total allowable for the claim is $2,200 Balance that remains after primary payment is $280 Since $280 is less than the amount that the secondary plan would pay if there was no other coverage, the secondary plan pays $280. Impact of the primary payment on the secondary carrier is $2020: $100 contractual write-off $1920 payment SVC*HC:59510*2500*280~ CAS*OA*23*2020~ CAS*CO*45*200~ 3. Other statues the affect COB Charge $2,500 Primary Plan Payment $1,555 Primary Plan Allowable: $2,200 Secondary Plan Benefit in absence of other coverage: $2160 Secondary Plan Allowable: $2,700 COB Calculation: Total allowable for the claim is $2,700 The statue mandates payment up to the allowable even when greater than the charge. Since the difference between the $2700 allowable and primary payment is $1145, the secondary plan pays this amount. Impact of the primary payment on the secondary carrier is $1555: SVC*HC:59510*2500*1145~ CAS*OA*23*1555~ CAS*OA*94*-200~ 4. Integration of Benefits: Charge $2,500 Primary Plan Payment $1,920 Primary Plan Allowable: $2,400 Secondary Plan Benefit in absence of other coverage: $1, /06/2007

11 Secondary Plan Allowable: $2,200 COB Calculation: Since the secondary payment would have been less than or equal to the primary payment, no additional benefits are due. Impact of the primary payment on the secondary carrier is $2020: $100 contractual write-off $1920 payment SVC*HC:59510*2500*0~ CAS*OA*23*2020~ CAS*CO*45*200~ CAS*PR*2*280~ 5. Reversal and Correction: Charge $2,500 Primary Plan Payment should have been $1,000 Primary Plan Allowable: $2,400 Secondary Plan Benefit in absence of other coverage: $1,555 Secondary Plan Allowable: $2,200 SVC*HC:59510*-2500*0~ CAS*CR*23*-2020*45*-200*2*-280~ COB Re-Calculation: Since the secondary payment is greater than the primary payment, an additional $555 is payable. Impact of the primary payment on the secondary carrier is $1100: $100 contractual write-off $1000 payment SVC*HC:59510*2500*555~ CAS*OA*23*1100~ CAS*CO*45*200~ CAS*PR*2*645~ 6. Unbundling: charge $ /06/2007

12 Both payers agree that and should have been billed. Primary plan payment is $100 Primary plan allowable is $120 Secondary Plan Benefit in the absence of other coverage $150 Secondary Plan Allowable is $150 COB Calculation: Total allowable for the claim is $150 Balance that remains after primary payment is $20 Since $20 is less than the amount that the secondary plan would pay if there was no other coverage, the secondary plan pays $20 Impact of the primary payment on the secondary carrier is $130 OPTION 1: $30 contractual write-off $100 payment SVC*HC:17000*150*10**1*HC:17003~ CAS*OA*23*65~ CAS*OA*45*75~ SVC*HC:17001*0*10**1*HC:17003~ CAS*OA*23*65~ CAS*OA*94*-75~ OPTION 2: SVC*HC:17000*150*20~ CAS*OA*23*130~ Group decided Option 1 is the preferred method of reporting an unbundled claim. Option 2 would be only be used when a payer agrees with how the provider billed the services. 7. Bundling: charge $ charge $1500 Both payers agree that the services should be bundled under Primary plan payment is $2700 Primary plan allowable is $3000 Secondary Plan Benefit in the absence of other coverage $2000 Secondary Plan Allowable is $ /06/2007

13 COB Calculation: Total allowable for the claim is $3000 Balance that remains after primary payment is $300 Since $300 is less than the amount that the secondary plan would pay if there was no other coverage, the secondary plan pays $300 Impact of the primary payment on the secondary carrier is $ Bundling: $500 contractual write-off $2700 payment SVC*HC:43000*2000*300**1:HC:44144~ CAS*OA*23*3200~ CAS*OA*94*-1500~ SVC*HC:43000*1500*0**1*HC:44000~ CAS*OA*97*1500~ charge $ charge $1500 Primary plan bundles charges under Secondary plan does not bundle these services. Primary plan payment is $2700 Primary plan allowable is $3000 Secondary Plan Benefit in the absence of other coverage $2000 Secondary Plan Allowable is $2500 COB Calculation: Total allowable for the claim is $3000 Balance that remains after primary payment is $300 Since $300 is less than the amount that the secondary plan would pay if there was no other coverage, the secondary plan pays $300 Impact of the primary payment on the secondary carrier is $3200 $500 contractual write-off $2700 payment SVC*HC:44144*2000*0~ CAS*OA*23*2000~ SVC*HC:44000*1500*300~ CAS*OA*23*1200~ 13 04/06/2007

14 HIR 495 Title Secondary Claim and Bundling Description While the 4010 guide does not include secondary claim instructions explicitly, I have run into a problem with a secondary claim that includes bundling. The secondary 837 requires that the primary payer bundling be reported. If the secondary payer bundles the same way, which adjustment should be reported on the secondary 835's bundled lines that do not pay? The one related to bundling, or the one related to the primary payer? bundling - CAS*CO-or-PI*97*$$$ or Secondary - CAS*OA*23*$$$ Response: The instructions that should be followed are the bundling instructions in section Bundling and Unbundling of the A1X091 When reporting secondary payments in the 835, the payer reports the impact of the primary payer's payment upon the secondary transaction. In this case, the secondary payer would report the amount not paid due to bundling with CAS*OA*23*$$$. Since the primary adjustment has already been posted, using CAS*CO-or- PI*97*$$$ would create a credit balance in the provider's account receivable system. Related HIR by WG: 496 HIR 496 Title Secondary Clm & Bundling 2 Description While the 4010 guide does not include secondary claim instructions explicitly, I have run into a problem with a secondary claim that includes bundling. The secondary 837 requires that the primary payer bundling be reported. When the secondary payer does not bundle and pays on the separate lines, there is a posting problem for the provider - those lines were written off by CO or PI adjustments from the primary. How should the secondary payment be reported in this case? Separately on the individual lines or on the combined (bundled) service that the primary adjudicated? Related HIR by WG: 495 The secondary payer follows their own business rules. They do not have to process the same as the primary payer processed the charge or report it in the 835 based on how the primary payer s 835. Secondary payer would report secondary lines submitted. However, they are obligated to report the impact primary payment with the CARC 23 code payer adjudication including payments and/or adjustments (OA*23) Review of the Lunch and Learn on new elements and segments from This presentation can be located at WPC-EDI Review the notes consolidation work done so far Review with the WG Wednesday. Next phase once we are ok with our notes these notes will be compared to other guides to make sure that all the guides have the same interpretation of the note. 10:00AM Review of the TG2 management meeting 14 04/06/2007

15 Explain what we are going to change in the RAS Semantic note Was a friendly amendment. Review of the process for handling the notes consolidation. Next Lunch and learn PLB What is the use of this segment reference ID s etc How is the receiver expected to react to it Expected behavior Doug Bob Poz Barb Jodi Present the possibility of doing educational sessions alone or in conjunction with another WG Create a possible plan for this and pricing structure. Sumita Carol Bob co-chairs ETA 1 Month Workgroup worked on sections of the notes to review and indicate changes / edit. Review until Lunch. Kim brought up a situation where he is being asked to supply the repricer name. There is currently not a situation that is supported in the has information in the REF 2100 CE Bob and Kim talked about adding a new NM1 to support this. This would require a DM We could submit a DM request have it get to TAS It will be deferred and we could still get it in for 5010 Bob suggests that there was a need some time ago and Medicare had a need for another crossover carrier and there is only one crossover carrier and they needed additional places to report them. Options were considered PER CR REF CR NM1 DM and CR For the New NM1 segment expanding Barb found the qualifier TU Third party repricer organization. UPDATE: found that there is room for 2 more NM1 segments to be added. Working on the rest of the notes consolidation. THURSDAY, FEBRUARY 01, 2007: HSA discussion and reporting on 835. Thanked WG for work on completing initial review of 269/835 Note Consolidation project. TG4 asked that we work with TG2WG4 (820 IG) on the first cross WG note consolidation. We share Table 1 so this would be a good exercise to see how it will work. CICA 835 mock-up presentation by Bob Poiesz Next steps: Database that represents the business XML language (X12C defines the rules of how to create the XML output) 1. Define beginning conditions that trigger an Develop business Use Cases for each component of the transaction. 3. Develop scrip per case that outlines: 15 04/06/2007

16 Before During After 4. Modelers take over 5. CICA 835 book can be written Bob commented that CICA model has application for Real Time Adjudication Entities that have created and/or use CICA models Banking industry Some government agencies Transportation has 3 CICA models X12N has coverage request and response approved DISA has an XML translator WG feels that momentum has needs to continue. This may not be implemented for 20+ years in our industry. If X12C Subcommittee were to move on their efforts in CICA - then this could replace HIPAA. Greg suggested: 1. Define process/methodology (TG3WG3) 2. Have small group work independently 3. Set time on Trimester agenda for CICA subgroup to get approval for work and guided input from WG3 Bob suggested beginning with interactive (835) response before tackling the 835. WG agreed. Volunteers: No volunteer stepped forward to lead, but the following people were willing to help: Barb Sesney, Greg, Bob Poiesz, and Pam Catrell. Greg has extensive modeling/use case experience, but due to possible changes at work, he may not be able to attend future X12 meetings. Pam has experience as well. Barb volunteered to develop one use case to present to during the June Trimester Meeting. Barb will have someone from company who has use case development experience work with her. Bob, Pam, and Greg will review use case. WG agreed that this is a starting point. Co-Chairs will follow-up with larger workgroup Question asked of WG: Healthplan has a business interpretation that is different than one of their vendors. Claim frequency code in CLP09 segment has to be returned on institutional claim. Recommended that two questions be posted to the Portal: Question 1: Are inpatient and outpatient claims both institutional (837I)? Question 2: What value must be returned in CLP09 of the 835 for an institutional claim? 16 04/06/2007

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