The HIPAA transactions and code set standards are rules that standardize the electronic exchange of health-related administrative information, such as claims forms. The rules are based on electronic data interchange (EDI) standards, which allow for the exchange of information from computer-to-computer without human involvement.
|Claim/encounter||X12 837||For submitting claim to health plan, insurer, or other payer|
|Eligibility inquiry and response||X12 270 and 271||For inquiring of a health plan the status of a patient.s 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 response||X12 276 and 277||For inquiring about and monitoring outstanding claims (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 authorizations||X12 278||For obtaining referrals and authorizations accurately and quickly, and for receiving prior authorization responses from the payer or utilization management organization (UMO) used by a payer.|
|Health care payment and remittance advice||X12 835||For replacing paper EOB/EOPs and explaining all adjustment data from payers. Also, permits auto-posting of payments to accounts receivable system.|
|Health claims attachments (proposed)||X12 275||For sending detailed clinical information in support of claims, in response to payment denials, and other similar uses.|
How EDI Works
Why You Need EDI – the Benefits
- Lower costs
- Higher efficiency
- Improved accuracy
- Enhanced security
- Greater management information
Professional billing is responsible for the billing of claims generated for work performed by physicians, suppliers and other non-institutional providers for both outpatient and inpatient services. Professional charges are billed on a CMS-1500 form. The electronic version of the CMS-1500 is called the 837-P, the P standing for the professional format.
Institutional billing is responsible for the billing of claims generated for work performed by hospitals and skilled nursing facilities. Institutional charges are billed on a UB-04.
Both sets of 837 specifications are same. The only differences would be claim specific data that pertains to a single transaction. All three transactions contain ISA, GS and ST segments but some data and qualifying codes are specific to the type of 837. Another way to quickly identify which type of 837 is being encountered is by the codes sent in the GS-08 or in the ST-03. Professionals use a 005010X222, Institutional uses a 005010X223 and Dental uses a 005010X224.