Presentation on theme: "Presentation on HIPAA & EDI837 By Euclid Technologies."— Presentation transcript:
Presentation on HIPAA & EDI837 By Euclid Technologies
HIPAA EDI ANSIASCX12 EDI Transactions n numbers Loops Segments Dataset 837 OUTER STRUCTURE
HIPAA is the Health Insurance Portability and Accountability Act of 1996. A federal law that specifies the types of measures required to protect the security and privacy of personally identifiable health information. WHY HIPAA Reduces administrative burden and cost for providers and payers Creates a national standard for electronic transactions Increases speed of financial transactions resulting in faster payment for services Simplifies the exchange of information and reduces paperwork Provides a more complete picture of healthcare and improves quality Improves privacy and security of healthcare information What does HIPAA stands for
The transfer of structured data, by agreed message standards, from one computer system to another without human intervention or interference is called EDI (Electronic Data Interchange) EDI is governed by standards released by ASC X12 (The Accredited Standards Committee). Each release contains set of message types like invoice, purchase order, healthcare claim, etc called Transaction. Each message type has specific number assigned to it instead of name. For example: an invoice is 810, purchase order is 850 and healthcare claim is 837. What is EDI (Electronic Data Interchange)
A "transaction" is an electronic business document. Every new release contains new version number. Version number examples: 4010, 4020, 4030, 5010, 5030, etc. Major releases start with new first number. For example: 4010 is one of the major releases, so is 5010. However 4020 is minor release. Minor releases contain minor changes or improvements over major releases. validate EDI X12 data you need to know transaction number (message numeric name) and release version number. Both of those numbers are inside the file. Cont (EDI)
(Cont EDI) The Electronic Transactions 837Institutional Claims and Encounters 837Professional Claims and Encounters 837Dental Claims and Encounters 835Claim Payment and Remittance Advice 834Enrollment and Disenrollment 820Capitation Payment Transaction 276Claim Status Request 277Claim Status Response 270Eligibility Request 271Eligibility Response 278Referral Authorization (Request) 278Referral Authorization (Response)
Standard EDI X12 format data is text file separated by segment, element and sub-element delimiters (separators). You can open EDI X12 files using any text editor even standard Windows notepad.exe utility. Carriage return and line feed are not required characters by EDI X12 standard. Each segment is displayed on the separate line. In this example each segment ends with ~ (tilde) or * (star) or | pipe sign. That is so called segment separator or segment delimiter. Each segment starts with 2-3 letter code that identifies it. Cont EDI Segment ID Segment Terminator NM1*P2*1*Masterex*R~ Segment Delimiter
Some segments form EDI X12 envelope are common to all EDI X12 files and message types. Those segments are ISA, GS, ST, SE, GE, IEA. This set contains important information about trading partners (like Sender Id, Receiver Id, etc.). It also contains interchange, transaction group and transaction control numbers, counts, transmission dates and times, and more. (Cont EDI)
DETAILS Interchange Control Header ( ISA ) Functional Group Header ( GS ) Transaction Set Header ( ST ) Transaction Set Trailer ( SE ) Functional Group Trailer( GE ) Interchange Control Trailer ( IEA) ENVELOP
ISAGSSTactual dataSEGEIEA Contains addresses of sender and receiver Contains departmental address information Marks beginning of the actual transaction
Electronic transactions provide significant benefits compared with paper transactions: EDI streamlines transaction processing formats are pre-edited to reduce common errors in claims data entry. This reduces the re-entry of the same data. It also reduces delays caused by scanning and re-keying. EDI also reduces operating costs and increases staff productivity. Improves cash forecasting & cash flow. Faster submission of accurate claims results in quicker payments and reduced receivables. Provides positive acknowledgement of transaction receipt Eliminates the cost of handling and storing paper documents EDI Benefits
PAYEREMPLOYER Finance Claims Processing UR Case Management Member Eligibility PROVIDER Finance Patient Accnt/ Collections UR Case Management Registration/ Admitting Eligibility Inquiries 270 Eligibility Response 271 Ref Authorization 278 Claims Encounter 837 Claim Status Req 276 Claims Status 277 Pay Remittance 835 Enrollment 834 Electronic Data Interchange (EDI) Transactions Flow
There is typical EDI X12 837 Healthcare Claim (HIPAA) release version 4010.
Shows the footer Loop in the below diagram… (Cont EDI X12 837)
Control Numbers Each Header and Footer Loop in the envelope contains specific control number.
TRANSACTION FOR INSTITUTIONAL, PROFESSIONAL AND DENTAL CLAIMS AND/OR ENCOUNTERS. 837 Professional Health Care Claim - ASC X12N 837 (004010X098A1) 837 Institutional Health Care Claim - ASC X12N 837 (004010X096A1) 837 Dental Health Care Claim - ASC X12N 837 (004010X097A1) ASC X12 – 837 (HEALTH CARE CLAIMS)
Process Of 837 Claim MEMBER/SUBSCRIBER OR PATIENT PROVIDER -INSTITUTIONAL -PROFESSIONAL -DENTAL PAYEER CLEARING HOUSES 837/counter
TERMINOLOGY PROVIDER - In a generic sense, the provider is the entity that originally submitted the claim/encounter. A provider may also have provided or participated in some aspect of the health care service described in the transaction. Specific types of providers are identified in this implementation guide (e.g., billing provider, referring provider). SUBSCRIBER - The subscriber is the person whose name is listed in the health insurance policy. Other synonymous terms include “member” and/or “insured.” In some cases the subscriber is the same person as the patient. PATIENT - The term “patient” is intended to convey the case where the Patient loop is used. In that case, the patient is not the same person as the subscriber, and the patient is a person (e.g., spouse, children, others) who is covered by the subscriber’s insurance plan. PAYER – health insurance companies, HMOs, company health plans, and certain government programs that pay for health care, such as Medicare and Medicaid.
CATEGORYANSI ASC X12N 837 SUBMITTER / RECEIVERHEADER & 100A PROVIDER200A SUBSCRIBER /INSURED200B PATIENT DEMOGRAPHICS2010 BA OR 2000 C PATIENT UB CODED DATA 2300 PATIENT MEDICAL2300 PATIENT CHARGES2400 PATIENT PHYSICIAN2310 A, B,C
Batch — Typically grouped together in large quantities and processed en-masse. In a batch mode, the sender sends multiple transactions to the receiver, either directly or through a switch (clearinghouse), and does not remain connected while the receiver processes the transactions. Real Time — Transactions that are used in a real time mode typically are those that require an immediate response. In a real time mode, the sender sends a request transaction to the receiver, either directly or through a switch (clearinghouse), and remains connected while the receiver processes the transaction and returns a response transaction to the original sender. Typically, response times range from a few seconds to around thirty seconds, and should not exceed one minute. Methods Of Receiving and Sending 837 Transactions
837 Loop Format HEADER ST Transaction Set Header BHT Beginning of Hierarchical Transaction REF Transmission Type Identification LOOP ID 1000A SUBMITTER NAME (1) NM1 Submitter Name REF Submitter Secondary Identification PER Submitter EDI Contact Information LOOP ID 1000B RECEIVER NAME (1) NM1 Receiver Name Detail - Provider LOOP ID 2000A SERVICE PROVIDER HIERARCHICAL LEVEL (1) HL Service Provider Hierarchical Level LOOP ID 2010AA SERVICE PROVIDER NAME (1) // subloop or shorthand loop// NM1 Service Provider Name REF Service Provider Secondary Identification Detail - Subscriber
(Cont 837 Loop Format..) LOOP ID 2000B SUBSCRIBED HIERARCHICAL LEVEL (>1) HL Subscriber Hierarchical Level SBR Subscriber Information PAT Patient Information LOOP ID 2010BA SUBSCRIBER NAME (1) NM1 Subscriber Name N3 Subscriber Address N4 Subscriber City/State/Zip Code DMG Subscriber Demographic Information REF Subscriber Secondary Identification LOOP ID 2010BC PAYER NAME (1) NM1 Payer Name REF Payer Secondary Identification Detail - Subscriber LOOP ID 2000C PATENT HIERARCHICAL LEVEL HL Patient Hierarchical Level LOOP ID 2010CA PATIENT NAME (1) NM1 Patient Name N3 Patient Address N4 Patient City/State/Zip Code DMG Patient Demographic Information REF Patient Secondary Identification
(Cont 837 Loop Format..) Claim LOOP ID 2300 CLAIM INFORMATION (100) CLM Claim Information DTP Statement Dates DTP Discharge Hour DTP Admission Date / Hour CL1 Claim Codes PWK Claim Supplemental Information AMT Payer Estimated Amount Due AMT Patient Estimated Amount Due REF Medical Record Number REF Mother’s Medical Record Number K3 File Information NTE Claim Note HI Principal Dx, Admitting Dx, and E-code HI Diagnosis Related Group (DRG) Information HI Other Diagnosis Information HI Principal Procedure Information HI Other Procedure Information HI Occurrence Span Code Information HI Occurrence Code Information HI Value Code Information HI Condition Code Information QTY Claim Quantity
(Cont 837 Loop Format..) LOOP ID 2310A ATTENDING PHYSICIAN NAME (1) NM1 Attending Physician Name REF Attending Physician Secondary Information LOOP ID 2310B OPERATING PHYSICIAN NAME (1) NM1 Operating Physician Name REF Operating Physician Secondary Information LOOP ID 2310C OTHER PHYSICIAN NAME (1) NM1 Other Physician Name REF Other Physician Secondary Information LOOP ID 2310D REFERRING PHYSICIAN NAME (1) NM1 Referring Physician Name REF Referring Physician Secondary Information LOOP ID 2320 OTHER SUBSCRIBER INFO (10) SBR Other Subscriber Information AMT Payer Prior Payment LOOP ID 2330A OTHER SUBSCRIBER NAME (1) NM1 Other Subscriber Name REF Other Subscriber Secondary Information
(Cont 837 Loop Format..) LOOP ID 2330B OTHER PAYER NAME (1) NM1 Other Payer Name REF Other Payer Secondary Information LOOP ID 2330C OTHER PAYER PATIENT INFO (1) NM1 Other Payer Patient Information REF Other Payer Patient Identification Number LOOP ID 2400 SERVICE LINE NUMBER (1) LX Service Line Number SV2 Institutional Service Line Information DTP Service Line Date
Header ST*837*987654~ BHT*0019*00*A12345*20010801*1800~ 0019—hierarchel structure code, 00– original, A12345– submitter batch control number, 29919891– date, 1800– time of file created Loop 1000A – Submitter Name NM1*41*2*TOO GOOD HOSPITAL*****46*999008888~ Loop 1000B – Receiver Name NM1*40*2*MY STATE DATA AGENCY*****46*12000~ Loop 2000A – Service Provider Hierarchical Level for Too Good Hospital HL*1**20*1~ Loop 2010AA – Service Provider Name for Too Good Hospital NM1*85*2*TOO GOOD HOSPITAL*****24*999008888~ REF*1J*898989~ Loop 2000B – Subscriber (Patient) Hierarchical Level for Scott Greene HL*2*1*22*1~ SBR*P********BL~ Loop 2010BA – Subscriber (Patient) Name for Scott Greene NM1*IL*1*GREENE*SCOTT*A**MI*GRNESSC1234 ~ N3*1313 MOCKINGBIRD LANE~ N4*ANYTOWN*NY*09090~ DMG*D8*19760706*M**::RET:3::RET:2~ REF*SY*130281234~ SY– functional category, 130281234— institutioanl implementation guide. Loop 2010BC – Payer Name Transaction 837 Example
NM1*PR*2*EMPIRE BLUE CROSS*****PI*00303~ Loop 2300– Claim Information for Scott Greene CLM*ABH123456*5015***11:A:1~ DTP*096*TM*1200~ DTP*434*RD8*20010610-20010611~ DTP*435*DT*200106100900~ CL1*2*1*01~ REF*EA*ABHMEDRECMOM~ NTE*UPI*STATE SPECIFIC REQUIREMENTS~ HI*BK:66411*BJ:66411~ HI*BF:66331:::::::Y*BF:66111:::::::N*BF:V270:::::: :N~ HI*BR:7569:D8:20010610~ HI*BQ:7309:D8:20010610~ Loop 2310A – Attending Physician Name for Scott Greene NM1*71*1*DOCTOR*JOE****XX*F88888~ REF*1G*JDUPIN~ REF*0B*JDSTAATE~ Loop 2310B – Operating Physician Name for Scott Greene NM1*72*1*SURGEON*REALGOOD****XX*F9999 9~ REF*0B*RSUPIN~ REF*1G*RSSTA Loop 2320 – Other Subscriber Information for Scott Greene SBR*S********CI~
Loop 2330A – Other Subscriber Name for Scott Greene NM1*IL*1*Greene*Beth*P~ Loop 2400 – Service Line Number for Scott Greene LX*1~ SV2*001**5015- LX*2~ SV2*122**2754*DA*2*1377~ LX*3~ SV2*258**15~ LX*4~ SV2*259**68~ LX*5~ SV2*279**59~ Loop 2000B - Subscriber (Patient) Hierarchical Level for Nancy Best HL*3*1*22*0~ PAT*********Y~ Loop 2010BA – Subscriber (Patient) Name for Nancy Best NM1*QC*1*BEST*NANCY*E**MI*BESTNA9999~ N3*1313 MOCKINGBIRD LANE~ N4*ANYTOWN*NJ*0*09090~ DMG*D8*20010610*F**::RET:3::RET:2~
Loop 2010BC – Payer Name NM1*PR*2*EMPIRE BLUE CROSS*****PI*00303~ Loop 2300– Claim Information for Bill Dunnet CLM*ABH123456*5015***11:A:1~ DTP*096*TM*1200~ DTP*434*RD8*20010610-20010611~ DTP*435*DT*200106100900~ CL1*2*1*01~ REF*EA*ABHMEDRECMOM~ NTE*UPI*STATE SPECIFIC REQUIREMENTS~ HI*BK:66411*BJ:66411~ HI*BF:66331:::::::Y*BF:66111:::::::N*BF:V270:::::: :N~ HI*BR:7569:D8:20010610~ HI*BQ:7309:D8:20010610~ Loop 2310A – Attending Physician Name for Bill Dunnet NM1*71*1*DOCTOR*JOE****XX*F88888~ REF*1G*JDUPIN~ REF*0B*JDSTAATE~ Loop 2310B – Operating Physician Name for Bill Dunnet NM1*72*1*SURGEON*REALGOOD****XX*F9999 9~ REF*0B*RSUPIN~ REF*1G*RSSTA
Loop 2320 – Other Subscriber Information for Bill Dunnet SBR*S********CI~ Loop 2330A – Other Subscriber Name for Bill Dunnet NM1*IL*1*Dunnet*Sue*O~ Loop 2400 – Service Line Number for Bill Dunnet LX*1~ SV2*001**5015- LX*2~ SV2*122**2754*DA*2*1377~ LX*3~ SV2*258**15~ LX*4~ SV2*259**68~ LX*5~ SV2*279**59~ LX*6~ SV2*305**38~ LX*7~ SV2*309**39~ LX*8~ SV2*729**2034~ LX*9~ SV2*999**8~ TRAILER SE*91*987654~
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