- Claims and encounters are created using the same EDI Transaction set 837.
- Claims are submitted to payer and request for payments for the service has been rendered by the provider
- Encounters are submitted to the payer for reporting purposes only.
- Encounter Services are reported under a capitated agreement in which payment is made outside of the delivery of the service as in a standard Fee For Service arrangement. The encounter is proof that the service was rendered by the provider.
- The EDI transaction sets such as the 837 Professional allows for the distinction of a claim and an encounter by indicating a "CH" (Chargeable) or "RP" (Reportable) in the sixth element of the BHT segment.
Example :
Claim Information
BHT*0019*00*0001*20200219*0749*CH
Encounters
BHT*0019*00*0001*20200219*0749*RP
Interest to see the real world example, try our EDI Tool here
https://demo.nagatabilling.com/NagataEDITool/login.zhtml
JSON TO EDI 837p
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