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

2. 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

3. ELECTRONIC DATA INTERCHANGE

4. 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

5. 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

6. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

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

17. 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

18. 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

19. INTERACTIVE TRANSACTIONS

20. 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

21. 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

22. 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

23. 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

24. Workbook chapter 8
Assignment 8-1