Healthcare Domain for BA

EDI Transactions
Presented by Raghu

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Healthcare Domain for BAs
• Day-1: Health Insurance - Overview
• Day-4: EDI Transactions-II
1.What is Health Insurance
2.Components of Health Insurance 1. ICD-9 vs ICD-10
3.Types of Health Insurance Coverages 2. 5010 EDI Format
4.Types of Health Insurance (HMO, PPO, POS)
5.Provider vs. Payer, and NPI
3. DRG, CPT, HCPCS
• Day-2: Claims Process 4. TR3, Companion Guide
1.Claims Process Flow • Day-5: Facets - Overview
2.Claims Management Revenue Cycle
3.Elements of Claim
1. Facets Functional Modules
4.Claims Submission 2. Data Model
5.Claims Adjudication Processing 3. Pricing Workflow
6.Encounters Submission
7.Compliance Check 4. DRG Processing
• Day-3: EDI Transactions-I 5. Government Health Reforms
1.837 EDI Claims 6. HIPAA Compliance at Work Place
2.835 Remittance
3.Edits and Validations
4.Reports and Acknowledgements
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Healthcare Domain for BAs
3.1 837 EDI Claims
• Electronic Data Interchange (EDI) is the – Benefits of EDI include:
computer-to-computer exchange of business • Reduced cycle time
data in standard formats. In EDI, information
• Better inventory management
is organized according to a specified format
set by both parties, allowing a "hands-off" • Increased productivity
computer transaction that requires no • Reduced costs
human intervention or rekeying on either • Improved accuracy
end. • Improved business relationships
• Enhanced customer service
• The EDI standards are developed and • Increased sales
maintained by the Accredited Standards • Minimized paper use and storage
Committee (ASC) X12. The standards are
• Increased cash flow
designed to work across industry and
company boundaries. The X12 standards
specify only the format and data content of
e-business transactions.

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Healthcare Domain for BAs
3.1 837 EDI Claims
• Electronic Data Interchange (EDI) is the – An EDI message (called transaction
computer-to-computer exchange of business set) is composed of related data
data in standard formats. In EDI, information segments – strings of data elements;
is organized according to a specified format with each element separated by a
set by both parties, allowing a "hands-off" delimiter. Each data elements
computer transaction that requires no represents a business parameter, for
human intervention or rekeying on either example a Member ID, Group, Provider
end. ID and Procedure Code.

• The EDI standards are developed and

maintained by the Accredited Standards
Committee (ASC) X12. The standards are
designed to work across industry and
company boundaries. The X12 standards
specify only the format and data content of
e-business transactions.

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Healthcare & Health Insurance - Overview
1. The HIPAA transactions and code set standards are rules that
standardize the electronic exchange of health-related administrative
information, such as claims forms.

2. The rules are based on electronic data interchange (EDI) standards,

which allow for the exchange of information from computer-to-
computer without human involvement.

3. A "transaction" is an electronic business document. Under HIPAA, a

handful of standardized transactions will replace hundreds of
proprietary, non-standard transactions currently in use. For example,
the HCFA 1500 claims form/file will be replaced by the X12 837
claim/encounter transaction.

4. Each of the HIPAA standard transactions has a name, a number, and a

business or administrative use. Those of importance in a medical
practice are listed in the table below:
Healthcare & Health Insurance - Overview
Name of transaction Number Business use
Claim/encounter X12 837 For submitting claim to health plan, insurer, or other payer

Eligibility inquiry and X12 270 and 271 For inquiring of a health plan the status of a patient.s
response eligibility for benefits and details regarding the types of
services covered, and for receiving information in response
from the health plan or payer.

Claim status inquiry and X12 276 and 277 For inquiring about and monitoring outstanding claims
response (where is the claim? Why haven't you paid us?) and for
receiving information in response from the health plan or
payer. Claims status codes are now standardized for all
payers.

Referrals and prior X12 278 For obtaining referrals and authorizations accurately and
authorizations quickly, and for receiving prior authorization responses from
the payer or utilization management organization (UMO)
used by a payer.

Health care payment and X12 835 For replacing paper EOB/EOPs and explaining all adjustment
remittance advice data from payers. Also, permits auto-posting of payments to
accounts receivable system.

Health claims attachments X12 275 For sending detailed clinical information in support of claims,
(proposed) in response to payment denials, and other similar uses.
 Healthcare & Health Insurance -
Overview
The 837 Health Care Transaction Set –
• The standard format developed by ASC X12 for health care claims
submission through electronic data interchange is called as “837
Transaction Set”.
• A successful EDI transmission requires the health plan to have
strong working relationship with their trading partners. Prior to
each implementation, it is essential that each health plan and its
trading partners have a clear and common understanding on
the contents of the claim data to be submitted to claims
processing system.

• The claim submission to be in 837 format.

• The version of the format to be submitted should be 4010 or
5010.
• Claims should contain Provider and Member identifiers.
• Validate membership data submitted with claims.
Healthcare & Health Insurance - Overview
The EDI 837 Inbound Process will convert the load of ANSI X12 Std
837 formatted claims to the Facets database.

The 837 process will –

• Read the file containing 837 formatted claims.
• Map the 837 fields to facets.
• Write claims to an intermediate work file
• Report on errors and run controls
• Read the intermediate work file
• Generate the claim numbers
• Generate facets claim acknowledgements.
The purpose of Companion Guide is to provide the information necessary to submit
claims/encounters electronically. The guide is to be used in conjunction with the
Implementation Guide (TR3). The information in CG describes specific requirements for
processing data within the payer‟s system. The companion guide supplements, but does
not contradict or replace any requirements in the IG. The implementation guide (a.k.a
TR3) is available for download on their web site at http://www.wpcedi.com/hipaa/.
Healthcare & Health Insurance - Overview
Understanding Health Information Privacy
• The HIPAA Privacy Rule provides federal protections for personal
health information held by covered entities and gives patients an
array of rights with respect to that information.

• At the same time, the Privacy Rule is balanced so that it permits

the disclosure of personal health information needed for patient
care and other important purposes. 

• The Security Rule specifies a series of administrative, physical,

and technical safeguards for covered entities to use to assure the
confidentiality, integrity, and availability of electronic protected
health information. 
Healthcare & Health Insurance - Overview
Healthcare & Health Insurance - Overview
For Covered Entities
The Privacy and Security Rules apply only to covered entities.  Individuals,
organizations, and agencies that meet the definition of a covered entity under
HIPAA must comply with the Rules' requirements to protect the privacy and
security of health information and must provide individuals with certain rights
with respect to their health information
Healthcare Domain for BAs

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Healthcare Domain for BAs
HIPAA Transactions
Transactions prior to treatment
• Eligibility Verification (270/271)
• Authorization/Referral (278)
Claims and related transactions Claims (837)
• Remittances (835)
• Claim Status (276/277)
Managed care transactions
• Enrollment (834)
• Premium Payment (820)
• Encounter (837)

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Health Care Provider Payers

837 - Claim

276 – Claim Status Report Claims

Billing 277- Claim Status Response Adjudication
835 – Claim Payment

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The 837 Transaction
The HIPAA-mandated transaction to be used for
the electronic transfer of health care claims or
equivalent encounter information is the ASC X12N
837 Health Care Claim, Version 5010.
• Professional
• Institutional
• Dental

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Provides standard format for electronic transfer of:
• Claims data
• Claim replacements and voids
• Encounter data

Professional Institutional
• Practitioners • Inpatient hospitals
• Ambulance service • Outpatient hospitals
• Clinical labs • Long-term care facilities
• Medical suppliers • Home health agencies
• DME suppliers • Hospices
• Hearing aid dealers
• Oxygen suppliers Dental
• Hearing and speech • Dentists (including all subspecialties)
• Orthotists/Prosthetists • Dental clinics

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Interactions with Other Transactions
Providers can supply certain information on the claim in
order to match it with the Remittance Advice.
• If this information is supplied in the 837 transaction, it
must be echoed on the 835 Remittance Advice.
– Includes:
• Patient Control Number
• Patient Account Number
• Medical Record Number

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ISA*00* *00* *01*9012345720000 *01*9088877320000 *100822*1134*U*00200*000000007*0*T*:~
GS*HC*901234572000*908887732000*20100822*1615*7*X*005010X222~
ST*837**005010X222~
BHT*0019*000007*123BATCH*20100822*1615*CH~ Sample 837 File
NM1*41*2*ABC CLEARINGHOUSE*****46*123456789~ Submitter
PER*IC*WILMA FLINTSTONE*TE*9195551111~ Contact info
NM1*40*2*BCBSNC*****46*987654321~ Payer Transaction Structure Level
HL*1**20*1~ • ISA/IEA Interchange Control
• GS/GE Functional Group
NM1*85*1*SMITH*ELIZABETH*A**M.D.*XX*0123456789~ Billing Provider
N3*123 MUDD LANE~
N4*DURHAM*NC*27701~
• ST/SE Segment
REF*EI*123456789~ Employer# • Detail Segments
HL*2*1*22*0~
SBR*P*18*ABC123101******BL~ Group#
NM1*IL*1*DOUGH*MARY*B***MI*24670389600~
N3*P O BOX 12312~ Subscriber address
N4*DURHAM*NC*27715~
DMG*D8*19670807*F~
NM1*PR*2*BCBSNC*****PI*987654321~
CLM*PTACCT2235057*100.5***11::1*Y*A*Y*N~
REF*EA*MEDREC11111~
HI*BK:78901~ ICD#
LX*1~
SV1*HC:99212*100.5*UN*1*12**1**N~ service
DTP*472*D8*20100801~ Date of Service
SE*24*0007~
GE*1*7~
IEA*1*000000007~
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Sample 837 File

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Sample 837 File

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ST*835*1234~
BPR*I*1922.86*C*CHK************20110108~
TRN*1*02790758*560894904~
Sample 835 File
REF*F2*LCLA438D~
DTM*405*20110104~
N1*PR*BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA~ CLP01: This data element
N3*P O BOX 2291~ references the “Patient
N4*DURHAM*NC*27702~
PER*CX*TE*8005554844~ Control/Account Number”
N1*PE*XYZ HEALTHCARE CORPORATION*XX*0987654321~ submitted on either the 837
N3*P O BOX XYZ~
N4*CHARLOTTE*NC*28234~
Institutional or the 837
REF*TJ*123456789~ Professional (Loop 2300 CLM01);
LX*1~
CLP*200200964A52*1*2100*1922.86*142.54*15*94151100100~
NM1*QC*1*Dough*Mary****MI* YPB123456789001~
DTM*050*20110103~
SVC*HC:59430*1210*1057.86**1*HC:59410~
DTM*472*20101231~
CAS*CO*42*34.6~
CAS*PR*2*117.54~
REF*6R*0001~
AMT*B6*1175.4~
SVC*HC:59440*890*865**1*HC:59410~
DTM*472*20101231~
CAS*PR*3*25~
REF*6R*0002~
SVC*HC:59426******742*742**1~
DTM*472*20101231~
REF*6R*0003~
AMT*B6*742~
SE*33*1234~
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Healthcare Domain for BAs

Data Overview
Six important types of information in the 837 transaction:
• Submitter/Receiver
• Provider
• Subscriber/Patient
• Claim
• Service Line
• Coordination of Benefits (COB)

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Healthcare Domain for BAs
Submitter/Receiver Information

Submitter
• Entity Name
• ETIN/Primary ID Number
• Contact Name
• Contact Communication Information
Receiver
• Name
• Receiver ID

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Submitter/Receiver Information Example

NM1*41*2*SUBMITTER CLEARINGHOUSE CORP*****46*0079~

PER*IC*SALLY SMITH*TE*2484890000~
NM1*40*2*MDCH MEDICAID FFS*****46*D00111~

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Healthcare Domain for BAs
Billing Provider Information

• Name
• Address
• Telephone Number
• SSN or EIN
• Medicaid Provider ID

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Billing Provider - Professional

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“Reading” EDI

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• Name
• Address
• Beneficiary ID
• Gender
• Date of Birth
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Subscriber/Patient Similarities
Identical across all claim types
• NM1: Name; includes Beneficiary ID
• Nx (N3, N4): Address
• DMG: Demographic Info; Date of Birth, Gender

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Subscriber/Patient
Info Example
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Service Line Information

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LX*1~
SV1*HC:99201*50*UN*1*11**1**Y~
DTP*472*RD8*20010815-20010815~
LX*2~
SV1*HC:99213*100*UN*1*11**2**N~
DTP*472*RD8*20010822-20010822~

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Healthcare Domain for BAs

Example 1:
LX*1~
SV2*0120**3000*DA*30*100~
Example 2:
LX*1~
SV2*0420*HC:97016*100*UN*2~

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Healthcare Domain for BAs

LX*1~
SV3*AD:D2140*29****1~
TOO*JP*30*O~

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Coordination of Benefits
Service Line Level
• ID of payer who adjudicated the service line
• Adjudication date
• Amount paid for the service line
• Procedure code used for adjudication
• Paid units
• Service line adjustment(s) Claim Level
• Claim level adjustments
• Insured’s name, sex, DOB
• Amounts
• Other payer name, ID
• Assignment of benefits
• Patient signature indicator
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Provider-to-Payer-to-Payer COB Model

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Maximums and Limitations
• Recommended a maximum of 5,000 CLM segments in a single
transaction (ST-SE). [Implementation Guide recommendation]
• Accept a maximum of 100 repetitions of the 2300 CLM loop within
each patient/subscriber loop. [Implementation Guide requirement]
• Accept a maximum of 50 services line for Professional and Dental
claims. [Implementation Guide requirement]
• Recommended submitting 50 or fewer service lines for each
Institutional claim to avoid processing delays.

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Transaction Structure
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997 Functional Acknowledgement
• Allows multiple 837 transactions (ST-SE) in each functional group
(GS-GE).
• All the transactions in a single functional group must be a single
type (professional, institutional, and dental claims).
• Allows multiple functional groups in an interchange (ISA-IEA).
• A 997 Functional Acknowledgement is generated for each
functional group in an interchange.
• 997 Functional Acknowledgements include Data Segment (AK3)
or Data Element (AK4) information when appropriate for
rejections

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Healthcare Domain for BAs
997 Functional Acknowledgement

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Healthcare Domain for BAs
997 Functional Acknowledgement

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997 Functional Acknowledgement

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Interchange Control
Structure

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