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
Maintaining Patient Insurance
Many patients only have one insurance plan but it is possible for a patient to have two or three medical insurance policies. The first insurance billed would be the primary insurance. The next one billed would be the secondary, and the last would be the tertiary.
After payment is received from the primary
insurance, the secondary is then billed on a new claim
with the information regarding payment from the
primary insurance in the form of a photocopy of the
explanation of benefits. If there is a tertiary insurance,
it would be billed after payment from both the primary
and secondary insurances is received. Copies of both
the primary and secondary eobs would be attached to a
new claim with the tertiary insurance information on it.
Another example of a person having two insurances is when both the husband and the wife work and both are eligible for health benefits from their employers. Their own policy would be primary and the spouse’s would be secondary. If they have children there are rules that determine which policy is prime for the children.
How patient insurances are maintained in the EMR/PMS software's ?
Today, software's are maintaining the patient insurance in difference ways. Each method has its own cons and pros. I will list those methods which i found in my past experience.
Before getting into detail, let us see the terms "Primary", Secondary, Tertiary and 4th Insurance". In some software, instead of calling 4th Insurance, they will call as Quaternary Insurance.
Actually, there is no defined process or method to identify which is patient primary insurance , and which is patient secondary insurance, and so on. For more details, please download this article and you will know how it has been identified. Since there is no defined way, most of the time, reception people will enter the secondary insurance information into primary and vice versa. That's the reason, all the software's providing swapping option for the insurance
Here you can always maintain 2 or 4 insurance at active state. Give important to the word "Active" here. But, HIPAA EDI 837 Transaction allow up to 11 insurance. So what happens, at one point of time, the existing insurance get expired and patient got new insurance ? Well, you cannot remove that insurance from the system it because it is tightly linked to Billing (Claims) Module. So only the option is to de activate the existing primary insurance and add new insurance in the active state as primary Insurance.
Method : 2
In this method, initially, the insurance are maintained at the patient level. But when the claim is created, software will take a copy of all insurance and will maintain along with part of the claim details. So here, after the claim is created, the insurance at the patient level is plugged off and will not have tightly linked with the claim. If any error in the policy details, of course, first we should correct at the claim level and then at the patient level for error free future claims.
Method : 3
EDI Transactions
The HIPAA transactions1 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.
| Transaction | Number | Business use |
| 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
837 Professional
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.
837 Institutional
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.
Parse EDI 835 into PDF
Create CMS 1500 Form using JSON
Parse EDI 837p to CMS 1500 Form
For 837 Institutional sample, please check here
