The Following picture demonstrates how insurance company processing the claims received from the clearing house.
Techno-functional 15 Years EMR/PMS experience.Love to work in EMR, e-Prescription, HL7, Medical Billing, EDI 4010, EDI 5010, CMS 1500 FORM, etc. Email : vbsenthilinnet@gmail.com
Claims adjudication and payment
EDI 5010 Documentation 837 Professional - Loop 2330A Other Subscriber Name
2330A Other Subscriber Name
EDI 5010 Documentation 837 Professional - Loop 2310C Service Facility Location Name
2310C Service Facility Location Name
EDI 5010 Documentation 837 Professional - Loop 2310A Referring Provider Name
2310A Referring Provider
How to install Maven in the Windows
Let us see how we can first setup Maven in the Windows step by step.
EDI 5010 Documentation 837 Professional - Loop 2000C Patient Hierarchical Level
LOOP 2000C Patient Hierarchical Level and and LOOP 2010CA – Patient Name
EDI 5010 Documentation – 837 Professional IEA Interchange Control Trailer
IEA – Interchange Control Trailer
EDI 5010 Documentation 837 Professional - LOOP 2000B Subscriber Hierarchical Level
2000B Subscriber Hierarchical Level
Some Important Master screens for PMS
Last year I was involved in developing an independent system for PMS using VB6 with sql server 2005. I really enjoyed myself and love to work/complete that project. One of my best period in my life. But unfortunately, we could not able to market the product because of VB6 no longer used widely in the industry.
EDI 5010 Documentation–837 Loop 2000A - HL–Billing Provider Hierarchical Level
HL – Billing Provider Hierarchical Level
Physician Quality Reporting System - PQRS
Let me just summarized the information which i understood clearly about PQRS . The following information are taken from different websites and some of them of my own question and answer 
EDI 5010 Documentation 837 Health care claim : Professional
Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com
If you are new to Medical Billing, then please read this article first.
If you are new to EDI, then read the following articles
1. What is an EDI ?
2. EDI Transactions
3. Understanding EDI Structure
4. How to Read and Understand EDI File
5. EDI Instruction
6. Beginners Guide to EDI X12 (including HIPAA)
7. What is EDI Transaction Loops and Segments?
8. Understanding EDI-Loops, Segments, and Elements
We will see the complete documentation on 837 with different use case sample EDI File.
837 Loops (Click each of the loop to see the complete documentation)
EDI 837 Professional Loops and Segments
1. ISA Interchange Control Record
2. GS Functional Group Header
3. ST Transaction Set Header
4. BHT Beginning Hierarchical Transaction Segment
5. LOOP 1000A Submitter Name
6. LOOP 1000B Receiver Name
7. LOOP 2000A Billing Provider Hierarchical Level
8. LOOP 2010AA Billing Provider Name
9. LOOP 2000B Subscriber Hierarchical Level
10. LOOP 2010BA Subscriber Name
11. LOOP 2010BB Payer Name
12. LOOP 2000C Patient Hierarchical Level
13. LOOP 2300 Claim Information
13. LOOP 2300 Date information
14. LOOP 2300 CLIA Number
15. LOOP 2300 Prior Authorization or Referral Number
16. LOOP 2300 K3 Segment
17. LOOP 2300 Health care Diagnosis Code
18. LOOP 2310A Referring Provider Name
19. LOOP 2310B Rendering Provider
20. LOOP 2310C Service Facility Location
21. LOOP 2320 Other Subscriber Information (Coordination of Benefit COB)
22. LOOP 2330A Other Subscriber Name(Coordination of Benefit COB)
23. LOOP 2330B Other Payer Name (Coordination of Benefit COB)
24. LOOP 2400 Service Line
25. LOOP 2430 Line Adjudication Info (Coordination of Benefit COB)
26. SE Transaction Set Trailer
27. GE Functional Group Trailer
28. IEA Interchange Control Trailer
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EDI 837 Examples
Please note ; all these examples are tested against WPC First Pass software.
You can download trial version here.
Also, you can download the following trial version software to view/validate EDI File.
1. EDI Notepad
2. HIPPA Document Viewer 2
3. On Line Validator American Coders
4. On Line Validator EDIVance
The following open source converts X12 EDI File to XML and 1500.
OopFactory X12 Parser
The following URL discuss about other open source in EDI Software.
Comparing Open Source EDI Software
Download all EDI 837 Use cases
Sample EDI 837 File with different use case
| Use case 1 |
| Bill with Individual NPI Patient is same as the Insurer (Self). Bill to Patient Primary Insurance. No of Claims : 1 Claim No : 249 |
| Download All files |
| Use case 2 |
| Bill with Individual NPI Patient is same as the Insurer (Self). Bill to Patient Primary Insurance. No of Claims : 2 (Two different patients, same primary insurance and same rendering provider ) Claim No : 249 and 250 |
| Download All files |
| Use case 3 |
| Bill with Individual NPI Patient is same as the Insurer (Self). Bill to Patient Primary Insurance. Patient is referred by another Physician (Referring Provider) No of Claims : 1 No of Line Items : 4 Claim No : 251 |
| Download All files |
| Use case 4 |
| In use case 4, we will combine the above three use cases claims and make one EDI File. So this EDI File will contain 3 Claims |
| Download All files |
| Use case 5 |
| Bill with Group NPI Patient is same as the Insurer (Self). Bill to Patient Primary Insurance. No of Claims : 1 Claim No : 252 |
| Download All files |
| Use case 6 |
| In this use case, we will combine all the claims created so far (use case 1 to use case 5) and we will make as one EDI File. No Of Claims : 4 Claim No : 249, 250, 251 and 252 |
| Download All files |
| Use case 7 |
| Bill with Individual NPI Patient is NOT as Same as Insurer Bill to Patient Primary Insurance. No of Claims : 1 Claim No : 253 |
| Download All filess |
| Use case 8 |
| Bill with Individual NPI Patient is same as the Insurer (Self). Bill to Patient Primary Insurance. All Claim Level Date included : Date Onset (431), Date Initial Treatment (454), Date Last Seen (304), Date Acute Manifestation (453), Date Accident (439), Date Last Menstrual (484), Date Last X-Ray (455), Date Last Worked(297) No of Claims : 1 Claim No : 254 |
| Download All files |
| Use case 9 |
| Example for creating EDI for Secondary Insurance (Coordination of Benefits COB Segments) |
| Download All files |
| Use case 10 |
| Example for creating EDI for Secondary Insurance (Coordination of Benefits COB Segments) |
| Download All files |
| Use case 11 |
| Example for LOOP 2300 K3 Segment and CLIA Number |
| Download All files |
| Use case 12 |
| Example for creating EDI for Secondary Insurance for more than one line item (Coordination of Benefits COB Segments) |
| Download All files |
| Use case 13 |
| Example for creating EDI for Tertiary (3nd) Insurance for more than one line item (Coordination of Benefits COB Segments) |
| Download All files |
| Use case 14 |
| Bulk Volume Claims 20 Claims in one EDI File |
| Download All files |
You can download all use cases as one zip file here
Reference
- What is EDI?
- Beginners Guide to EDI X12 (including HIPAA)
- What is EDI Transaction Loops and Segments?
- Understanding EDI-Loops, Segments, and Elements
JSON to EDI 837 Professional
https://emrpms.blogspot.com/2020/04/json-to-edi-837-p.html
For more option, check our EDI Tool
URL : https://demo.nagatabilling.com/NagataEDITool/login.zhtml
User Name : demo
password : demo
Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com
Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com
EDI 5010 Documentation–837 - BHT - Beginning of Hierarchical Transaction
BHT – Beginning of Hierarchical Transaction
Hibernate Validator - Creating custom constraints @Required – Example 4
In this post, we will see how we can create our own custom constraints tailored to our specific requirements.
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