Electronic Data Interchange: Transactions and Security Chapter 8 Electronic Data Interchange: Transactions and Security

OBJECTIVES Advantages of electronic claim submission Transactions and code sets used for insurance claims transmissions Insurance claim data elements required or situational for the 837P standard transaction format Necessary components for a practice management system

ELECTRONIC DATA INTERCHANGE

Electronic Data Interchange (EDI) Sending and receiving health information electronically Used for transmission of insurance claims Transmitted data is encrypted Computer code in place of standard text for security Improves efficiency of claims submission

Covered Entity If you are a provider who bills to Medicare AND you bill electronically to any payer AND you have more than ten full-time employees THEN….. You are a covered entity and must file electronically

Electronic claim TRANSACTION/names ASC X12N 837P – electronic professional (physician) claim ASC X12N 837I – electronic institutional (facility) claim ASC X12N 835 – electronic payment ASC X12N 276 – electronic claim status ASC X12N 270 – electronic eligibility and benefits

ADVANTAGES OF ELECTRONIC CLAIM SUBMISSION More reliable and timely processing Quicker reimbursement from payer Improved accuracy of data Easier and more efficient access to information Better tracking of transactions Reduction of data entry and manual labor Reduction in office expenses

clearinghouses Claims are checked electronically Claims with missing/incorrect information are rejected Rejected claims are sent back to the provider with a report Batches of acceptable claims are sent to the appropriate payer Corrected claims are reprocessed

Advantages of a Clearinghouse Translation into HIPAA 5010 format Claim scrubbing Audit trail Proof of timely filing Improved cash flow Less time processing claims for submission Faster payment

Transaction and Code Set (TCS) Regulations Developed to improve efficiency in the healthcare system Higher quality of care with less administrative cost Streamline administrative and financial transactions Electronic Data Interchange Exchange of data in a standardized format through computer systems

Medical Code Sets Uniformly used data elements CPT-4, ICD-9-CM, HCPCS, ICD-10-CM Required for EDI

Code sets CPT HCPCS ICD-9 ICD-9-PCS ICD-10 Taxonomy codes Patient account number Relationship to patient Facility code value Patient signature source code

The Insurance Specialist Understands how practice management software works How PM pulls from data entry onto the claim How claims are transmitted from PM to clearinghouse Work rejection edits Receipt and download of electronic remits for posting Understands which codes are required Understands claims scrubbing and edits

The Practice management system Prepares, sends, receives, and processes electronic transactions Tracks receipt of Notice of Privacy Practices (NPP), patient treatment consents or authorization

Do’s and don’ts for keying insurance data for claim submission DO: use patient account numbers to differentiate between patients with similar names DO: use correct numeric locations of service codes, current valid CPT OR HCPCS codes DO: print an insurance billing worksheet or perform a front-end edit to look for and correct all errors before the claim is transmitted

Do’s and don’ts for keying insurance data for claim submission DO: request electronic-error reports from the third party payer to make corrections to the system DO: obtain and cross-check the electronic status report against all claims transmitted

INTERACTIVE TRANSACTIONS

Interactive transactions Back-and-forth communication between two computer systems Real-time communication allows instant information transfer Electronic funds transfer (EFT) can speed up reimbursement

Electronic remittance advice (ERA) ERA: online transaction about the status of a claim Medicare ERA Formerly called the Medicare explanation of benefits (EOMB or EOB) Based on Health Care Claim Payment/Advice (835) or ANSI 835

Transmission Reports Send and Receive Files Files received by clearinghouse Batch Claim Report Billed Summary Patient’s name and total charges billed Batch number, billing number Insurance company billed Chronologically the date(s) claim was transmitted Scrubber Report Total number of claims, charges, and dollar amounts received and scrubbed by the clearinghouse

Transmission Reports (cont’d) Transaction Transmission Summary Number of claims originally received by the clearinghouse and/or payer How many claims were rejected automatically Rejection Analysis Report Identifies most common reasons claims are rejected indicates what claims were not included for processing Corrections made and claim resubmitted Electronic Inquiry Claim Status Files received from the providers office Indicates the progress of the claim

Workbook chapter 8 Assignment 8-1