We envision an on-line, up-front query system in which the primary and secondary payers will be determined at or before the time that the care is provided, thus eliminating the need for after-the fact attempts to match data across various databases, or the continuation of the Medicare Data Bank
In 1993, the Workgroup on EDI said:
"To achieve the ultimate goal, a central directory of enrollment information must be maintained to determine primacy….The directory would receive enrollment information from insurers, apply the standard rules of primacy of coverage and payment responsibility, and code and array the policies for each insured individual accordingly."
In 1995, the US Office of Management and Budget testified to the Senate Finance Committee that
"We envision an on-line, up-front query system in which the primary and secondary payers will be determined at or before the time that the care is provided, thus eliminating the need for after-the fact attempts to match data across various databases, or the continuation of the Medicare Data Bank."
This is the technology under our patent claims, and the service we are deploying for you.
To achieve the ultimate goal of hands-free, online COB testing, Plan Sponsors (the only authoritative source of "who's covered where" data, and their TPAs have to complete three steps:
1. The Plan Sponsor or, in the case of a fully insured plan, the insurer, need to establish a contract with Digital Healthcare. This is because the NAIC regulations give the authority to "the plan sponsor and his agent" to exchange claims and coverage data without patient consent for the purpose of completing coordination of benefits.
2. An interface to synchronize eligibility data between the Plan Sponsor, his TPAs, and Digital Healthcare must be installed. Online eligibility verification is a mandated process under HIPAA, so establishing this interface is an investment everyone must make.
3. Your claim payers must install an interface to test each claim against our database and switching capacity to establish their primacy on each claim.
If your claims payers are running popular claims software packages, joint deployment agreements have been executed or at least offered to:
We've attached the data definition, the standardized transaction sets as defined by the American National Standards Institute that are mandated by HIPAA, to allow you to verify that all systems installations are done in accord with these requirements.
Notes for Payers and their Software Vendors:
The mandated data ANSI eligibility and claims data sets needed to complete an automated COB test are available here, as is the relevant section of HIPAA.
Digital Healthcare, PO Box 470732, Cleveland, OH 44147. Tel: 714-384-0179; Fax: 216-520-1261.