Change Request Detail
No.
1160
Date
7/22/2011
Submitter
Type of Request
Professional Claim (HCFA 1500)
Status
DSMO Process Completed
Business Reason
There is a need to data mine claims data for a variety of purposes.  One of those purposes is to determine what providers are charging for services (the retail charge).  This information is often required under state law to be presented to healthcare consumers or used to calculate usual and customary charges by CPT code. The necessity for accurate data is exemplified by the New York State lawsuit that charged a healthcare vendor of innacurately calculating UCR data to the detriment of providers as comingled in this data were charges required by federal or state laws that require the provider to charge amounts other than their true retail charge.  The lawsuit resulted in a substantial penalty being assessed to the vendor. Thus, the ability to clearly and accurately know when a particular charge is other than retail is the purpose of this request.  Fair Health, created by the State of New York to collect this kind of data, has determined that there is no other way to accurately do that without having the charge in the 837 identified as a retail charge or other than a retail charge.  They have a pressing need to get accurate data as soon as possible.  Getting the ability to capture this data element(s) to differentiate between retail and non retail, is requested to be included in the 6020 standard.
Suggestion

There are several ways this can be accomplished and we defer to the workgroup to make the final determination, but here are some approaches to consider:

1. A "flag" that notes whether it is retail or not.

2. A situational loop that only identifies it if it is not a retail charge.

3. A more robust set of identifiers that further define the non retail charge as being state required, federal required, contractually required, etc.

The actual possible processes have already been presented to the claims workgroup. They asked us to resubmit our request through this process.
DSMO Category
D
Recommendation
Disapprove. The business case brought forward by the requester was not felt to be sufficient to justify the change.
Appeal Recommendation