Healthcare IT EMR PMS: 2013

Note : In Medical Billing, people use different words for the same thing; Here are those most commonly used;

Doctor is also referred as Physician or Provider
Doctor Clinic is also referred as Doctor Office, or Physician Office or Provider Practice or Provider Facility; So facility or practice or clinic or office refers to the place where the patient meet the doctor;
Insurance is also referred as Payer or carrier

Use case 1 : In House Billing

Patient Calls / walks to the Physician(or Doctor or Provider) office to fix an Appointment.
On the Appointment day, patient checked in to the office and give all the demographics information such as last name, first name, DOB, address,etc and insurance information;
Doctor review the patient previous medical record and recommend the treatment to the patient for the current problem(or Disease);
Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code; ( ICD means International Statistical Classifications of Diseases. ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings.Some example for ICD Codes)
Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; (CPT means Current Procedural Terminology codes, are procedural codes published by the American Medical Association, describing what services the provider actually performed on the patient. Some example for CPT Codes)
Once all the process are over, now patient leaves the doctor room. Now the doctor office need to get paid for the service provided to the the patient;
Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to send bill(claim) to the insurance company;
Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
Once the claim is prepared and then it will be send to the Insurance company for payment;
Insurance company pays the doctor office;

Use case 2 : In House Billing with Two 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.

First the primary carrier must be billed first and then balance is billed to the second insurance carrier with the primary insurance payment information. If there is a third or tertiary insurance, it is billed last with payment information from the first two.

Patient Calls / walks to the Physician(or Doctor or Provider) office to fix an Appointment.
On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc) and insurance information;
Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code;
Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;
Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
Once the Claim is prepared and will be send to the Primary Insurance company for payment;
Primary Insurance company pays the doctor office;
Billing Department notified that claim has still some balance after Primary Insurance is paid. Since the Patient has another insurance (secondary), so now the billing department send the claim to the patient secondary insurance to collect the remaining balance.
Secondary Insurance Process the claim and pay the remaining amount to doctor office

Use case 3 : Self Pay

Patients who are not covered by health insurance(does not have any insurance) are considered “self pay” patients. They or the responsible party they designate are totally responsible for their own bill. Not everyone is covered by health insurance. The ones that aren’t covered are considered self pay and just like in the old days, these people must pay for their visits themselves.

Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc).
Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code;
Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;
Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
Once the Claim is prepared and since there is no insurance for the patient, so patient statement is generated and send to the patient for payment;
Patient Receives the Statement and Payment is made to the doctor office.

Use case 4 : Patient Responsibility

Some insurance policies pay a percentage rather than a set amount. Anywhere from 50% to 80% is very common for some insurance policies. Once they pay their portion, there may be a patient responsibility remaining. This amount is generally billed to the patient after the insurance payment is made.

Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc).
Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code;
Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;
Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
Once the Claim is prepared and send to the Primary Insurance company for payment;
Primary Insurance company pays only 80 % of the Bill to the doctor office;
Since there is no other insurance for the patient and claim balance is still 20 %, so now the billing department change the responsibility of the balance to patient and patient statement is generated.
Billing Department send the Statement to the Patient.
Patient Receives the Statement and Payment is made to the doctor office.

Use case 5 : Clearing House Work flow

Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc.) and insurance information;
Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code;
Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code;
Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;
Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
Once the Claim is prepared and send to the Insurance company for payment;
Billing Department using the Practice Management System (PMS), send the claim via EDI File. The EDI Transaction used to create the claim in the Electronic format is EDI 837
Refer the Following Link to understand more on EDI 837
What is an EDI ?
EDI 837 Health Care Claim
Once the 837 EDI File is created, then it will be send to the Clearing House.
Clearing House will validate the EDI File and send to the particular insurance company.
Insurance Company Process the Claim and prepare the Check (Cheque) and Statement(This statement is called Explanation of Benefits OR Remittance Advisory (EOB)
Refer the following Link for EOB
EOB - An explanation of benefits
Insurance company also generates the EDI 835 File using their System. EDI 835 is electronic version of EOB.
The Electronic Remittance Advice (ERA), or 835, is the electronic transaction which provides claim payment information in the HIPAA mandated ACSX12 005010X221A1 Format. These files are used by practices, facilities, and billing companies to Auto Posting payments into their systems.
Refer the following link for Sample
EDI 835 Health Care Claim Payment/Advice:
Once the Check, Statement (EOB) and ERA File are ready, then insurance company first send the ERA File and EOB to the clearing house.Second , insurance company will send the Check and copy of the EOB to the billing provider address . Third for each patient in the statement, the copy of the EOB will be emailed.
Now the Billing Team download the EOB and ERA from the clearing house. If the PMS system has Auto Posting Using ERA File, then they will download the EDI File and do auto posting. If there is no auto posting Module, then they will download the EOB PDF and apply posting manually.Remember, some time, ERA/EOB file will be reach the clearing house, even before the insurance company send the payment check to the doctor.

Use case 6 : Co-pay Work Flow

The co-payment or Co-pay is a payment defined in the insurance policy and paid by the insured person each time a medical service is accessed Co-pay: A co-pay is usually a flat fee. For example, every time you go to the doctor you pay a 25.00 co-pay for the office visit, regardless of the level of service you receive.

A co-payment, or co-pay, is the flat amount that need to pay by the patient at the time of medical service i,e at the time time of the visit to doctor office. All insurance companies provide these costs to you up front. Insurance companies use these co-pays in part to share expenses with you.

Patient walks into doctor office .
People at the Reception desk ask the patient insurance card (it is like credit card) and see any amount mention in the card as co-pay. If not, they will do the eligibility check and see whether any co-pay is required. Insurance eligibility check will give the complete details where insurance is active , any co-pay amount to be paid, etc..
Once they determined, if co-pay amount need to be paid, then reception desk will do either of the following

Will collect the amount and give the Patient receipt or Will Inform the patient that he/she need to pay copy after the Insurance payment is over. After insurance payment is over, we will send the patient statement to you and then you can pay your co-pay amount or Will inform the patient after the Insurance payment is over, we will send the claim to your secondary insurance and try to get the co-pay amount.

In most cases, doctor office will not collect the co-pay amount at the time of visit because either they may not known the exact amount or it may be cover by the secondary insurance. Please remember, the exact co-pay amount is calculated after insurance processing the claim and will be informed in the EOB.
Billing company send the claim to Insurance company.
Insurance company process the claim and if any co-pay has to paid by patient, then they will mention that amount in the EOB.
Now the billing company transfer that amount from insurance side to patient side if patient does not have secondary insurance. (Move to Patient responsibility) if patient has secondary insurance, then they will send to secondary insurance and try to collect it from secondary insurance. Please remember, while sending the claim to secondary insurance, we must send the patient primary insurance information and what amount has been paid and what amount has been left over.
If secondary insurance does not cover that amount, then it will be transferred to patient responsibility.

Use case 7 : Deductible Workflow

What does deductible mean in an insurance policy? It's the amount of a claim you are responsible for, before the insurance company will start paying it's share of costs.

Some insurance policies have a deductible that must be met before the insurance will pay for any services. The amount of the deductible varies depending on the policy. The patient is responsible to pay for all
amounts applied to the deductible.

Simple example, once you taken the policy , insurance company says, first patient has to Pay $ 500 and then insurance will start paying for the medical services

1. Patient walks into doctor office A.
2. Doctor done some medical services to Patient.
3. Billing Department send the claim to Insurance. Let the bill amount is $ 200.
4. Insurance find that the patient has to pay $ 500 first and then they can start paying.
5. Now the insurance company send the EOB saying $200 is Deductible. Please note, here insurance company does not pay any amount. And also the insurance company system reduces this $ 200 from $ 500 and update the record balance as $300 deductible balance
6. Billing Department transfer this $ 200 to patient responsibility if the patient does not have secondary insurance. If the
patient has secondary insurance, then claim send to secondary insurance for this amount.

**********************************
1. Same Patient walks into same doctor office A or doctor office B or lab.
2. Some medical Services done to Patient.
3. Billing Department send the claim to Insurance. Let the bill amount is $ 100
4. Insurance find that the patient has to pay $ 500 first and then they can start paying. And also records says $200 already met in the previous visit.
5. Now the insurance company send the EOB saying $100 is Deductible. Please note, here insurance company does not pay any amount.
And also the insurance company system reduces this $ 100 from $ 300 and update the record balance as $200 deductible balance.
6. Billing Department transfer this $ 100 to patient responsibility if the patient does not have secondary insurance. If the patient has secondary insurance, then claim send to secondary insurance for this amount.

**********************************

1. Same Patient walks into same doctor office A or doctor office B or lab.
2. Some medical Services done to Patient.
3. Billing Department send the claim to Insurance. Let the bill amount is $ 600
4. Insurance find that the patient has to pay $ 500 first and then they can start paying. And also records says $300 already met in the previous visit.
5. Now the insurance company send the EOB saying $200 is Deductible and Payment is $400
6. Billing Department transfer this $ 200 to patient responsibility if the patient does not have secondary insurance. If the
patient has secondary insurance, then claim send to secondary insurance for this amount.

Use case 8: Lab Billing

Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc.) and insurance information;
Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
Doctor Wants to check Blood test of the patient, so he request the patient leave the blood sample in the reception.

The above steps are usually handled in EMR Software running inside the doctor office.
Search Google : EMR lab request
Patient leave the blood sample in the container provided at the reception desk. If the EMR running inside the doctor office are integrated with Lab LIS, then via HL7, the doctor office place the order using the EMR software. if not integrated, the doctor office staff fill up lab requisition order form manually and send to the Lab via fax or email. Some LIS System having Doctor Portal where the doctor office staff can login and place the order in the portal.

Search Google : sample lab requisition form
Every day Lab Transportation department visits the doctor office and pick the patient samples and shifted to Lab on same day.

Search Google : Lab sample transportation
Once the Lab receives the Order form, it will be assigned to the lab technician to do the blood test. Test technician checks the blood sample and he prepares the Test result which contains various components with low/high value indication.

Step (3) 4 are usually handled in Lab LIS Software running inside the Lab .
Now the Lab has get to paid for their work. Since the patient has insurance, so the Lab team forwards all those information with final result to billing department to generate the claim and send to insurance company. If the LIS is integrated with Billing software, then information are send via HL7 to the Billing software. If not, lab team manually pass the information by creating as PDF and forward that to the Billing department.
Now billing billing department receives the final result with all patient demographics information and insurance information.
Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
Once the Claim is prepared and send to the Primary Insurance company for payment;
Primary Insurance company process the claim and send the payment to lab.

Step 6,7,8,9 are usually handled in Practice Management Software or Medical Billing running inside the Lab or Billing company where they outsourced their work.

So three systems are involved (EMR, LIS and PMS) to do Lab Billing. If the software supports HL7 Protocol, then the information can be easily passed between the system without manual data entry work.

HL7 is the standard to which healthcare application vendors adhere when developing application interfaces to exchange patient data. The HL7 standard defines a method of moving clinical data between independent medical applications in near real time

Example Conversation during Patient check In process.

Jake : Calls the MyfirstHealth Landline Number.

Linda : Hello, This is Linda from MyfirstHealth Clinic . How can i help you ?

Jake : Hi Linda, My Name is Jake,I would like to meet Dr John today evening after 5 PM.

Can you please confirm doctor appointment is available ?

Linda : Sure, Let me check my records. Yes doctor is available after 5 PM. Do you like book the appointment ?

Jake : Yes Can you please make it at 5.30 PM ?

Linda : Sure. May i know you are coming first time to this clinic or you have already came ?

Jake : This is the first Time;

Linda : Good. May Know your last name, first Name and DOB to make a note in my records.

Jake : My Last Name is Jake; My First Name is : mike; and my DOB is xx/xx/xxxx.

Linda : Ok Got It. Please come 15 min before the appointment, so that we can get all your insurance information,etc.

Jake : Ok Sure.

That's all

At 5.15, Jake arrives the clinic and meet the reception the Linda.

Jake : I am jake, I've appointment with the Doctor John at 5.30 PM

Linda : Welcome Jake; Let me pull your records from the desk.

Jake : Sure

Linda : Jake. Do you have insurance to cover your illness ?

Jake : Yes. I've Insurance.

Linda : Please give your insurance information, so that after the visit, we need to send the bill to the insurance company

Jake : I am working in a company called xxx , My employer covers my health insurance. Do you want to give that insurance
information ?

Linda : Yes Please.

Jake : Here you go. Insurance Name :xxxx. Policy No :xxxx, etc.

Jake : Wait a minute. Apart from my employer insurance, i also have taken family coverage from another insurance.
Do you want to give that information also ?

Linda : Yes Please

Jake : Here you go. Insurance Name :xxxx. Policy No :xxxx, etc.

Jake : Hey apart from employer and my family, I've also have another insurance under my own name ?
Do you want to give that information also ?

Linda : Yes Please
Here what Linda does in the records She marked Employer Insurance as Primary, and Family Insurance as Secondary and Its own Insurance as third.

Jake : Hey i've question. Why you are collecting all my three insurance ?

Linda : Well, Once your visit is over, we will send the bill to your employer information company first and once we receive the payment, we will check whether still the bill has some more balance. If there is balance, then we will send the bill again to your family insurance company and so on.

Jake : Oh it is great process. I got it.

Jake : But I've stupid question if you don't mind.

Linda : Please go ahead

Jake : If you send the bill to my family insurance again, then you will get paid twice :). So you will get two payment
for one service ?

Linda : No it is not like that way it works. Once we receive the payment from your first insurance, if there is balance, then we will send the bill to your second insurance along with the payment information of your first insurance. So your second insurance will check what is the first insurance paid and then they will pay only the remaining balance.

Jake : Wow that is great.

Jake : What happens if still there is balance in the bill, after my second insurance send the payment.

Linda : Well, since you have third insurance, we will send the bill again to your third insurance with the paid information from your first and second, so now your third insurance will know what has been paid by first and second insurance, then they will pay the remaining balance.

Jake : Wow that is really great process. You lot of work to do :)

Linda : Yes we always at your service sir.

Jake : But still I've another question if you don't mind ?

Linda : No problem. Go ahead

Jake : What happens if my bill still have balance after you paid from my third insurance ?

Linda : Well, Finally we will prepare the statement on your visit which will contains information about the service given and how much we got paid from all your insurance and at the bottom you can see how much you need to pay the balance. The statement will be mailed to you. Once you receive the statement, you can send the payment via check, or any other way.

Jake : Got It. I am done with my questions. Now what i want to do ?

Linda : Well. Please wait for 5 min. Our Nurse or Provider assistant will call you to do preliminary process.

Jake : Thank You.

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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

And also, we should know how secondary insurance billed and get paid. Please download this document to know more on that.

Now let us see how software's are maintaining the patient insurance.

Method 1 : Maintain 2 or 4 insurance at the Patient Level

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.

The advantages in this method is : Insurance are maintained only at one place i.e. at the patient level. So any changes done here, it will impact all the claims linked to that. This might be useful when there is error in the data entry and after the correction, they want to re submit all the claims linked to that insurance.

And also, at one point of time, there will be huge number in the inactive state, and no idea which claims are linked to that.

But what happen, if the patient is coming for two different visit types : For example, you may have a patient that is being treated for injuries sustained from an auto accident that is covered under one insurance policy; yet that same patient may receive treatment during the same visit for a condition unrelated to the auto accident where a different policy may be billed. So in this case, you need to maintain two primary insurance dependent on the visit type.In the above method, it is not possible, so that is one of the disadvantage.

Method : 2

Another way is to clone the patient demographics insurance while claim is created and therein after maintain the copy of all insurance at the claim level.

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.

if the patient is coming for two different visit types, then we can easily handle here because, we need to change only at the claim level.

Method : 3

And final method is patient case. This method not only to maintain the insurance, but it can also provide a template kind of stuff to create same kind of claim data for the same patient again and again to save the time.

In order understand, simply you can think patient case is nothing but to maintain group of insurances. Let us see detail now.

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.

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. 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.

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

Doctor diagnosis the patient and provide the treatment for the identified disease. Billing Team prepare the bill(claim) and the claim is transmitted into an EDI Document format called as 837 Health care claim. Then the EDI 837 Document securely transmitted to the insurance company via clearing house.

Then the Insurance company processes the claim which comes in the electronic format and provide the necessary reimbursement for the provider for the treatment given to the patient.

Why You Need EDI – the Benefits

Lower costs
Higher efficiency
Improved accuracy
Enhanced security
Greater management information

Interest to see some sample EDI Documents. Please check here.

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.

EDI Tool

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For 837 Institutional sample, please check here

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com.

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ISA – Interchange Control Header

The ISA is a fixed record length segment and all positions within each of the data elements must be filled. The first element separator defines the element separator to be used through the entire interchange. The segment terminator used after the ISA defines the segment terminator to be used throughout the entire interchange.This results in the segment terminator always being in position 106.

PMS Product Reference

	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
Header	ISA	Interchange Control Header		3		R	ISA
		Element Separator	AN	1			*
	ISA01	Authorization information qualifier	ID	2/2	101	R	00 or 03 See below for more information
		Element Separator	AN	1			*
	ISA02	Authorization information	AN	10/10	102	R	Will contain User ID if ISA01 is 03. Will Contain 10 Empty spaces if ISA01 is 00
		Element Separator	AN	1			*
	ISA03	Security information qualifier	ID	2/2	103	R	Will Contain 01 if ISA01 is 03. Will Contain 00 if ISA01 Is 00.
		Element Separator	AN	1			*
	ISA04	Security information	AN	10/10	104	R	Will contain Password if ISA01 is 03. Will Contain 10 Empty spaces if ISA01 is 00
		Element Separator	AN	1			*
	ISA05	Interchange ID Qualifier	ID	2/2	105	R	ZZ
		Element Separator	AN	1			*
	ISA06	Interchange Sender ID	AN	2/15	106	R	See below for more information
		Element Separator	AN	1			*
	ISA07	Interchange ID Qualifier	ID	2/2	105	R	01
		Element Separator	AN	1			*
	ISA08	Interchange Receiver ID	AN	15/15	107	R	See below for more information
		Element Separator	AN	1			*
	ISA10	Interchange Time	TM	4/4	109	R	Current Time in HHMM Format
		Element Separator	AN	1			*
	ISA11	Repetition Separator	ID	1/1	110	R	^
		Element Separator	AN	1			*
	ISA12	Interchange Control Version Number	ID	5/5	111	R	00501
		Element Separator	AN	1			*
	ISA13	Interchange Control Number	NO	9/9	112	R	000000001 (See below for more info)
		Element Separator	AN	1			*
	ISA14	Acknowledgement required
		Element Separator	AN	1			*
	ISA15	Usage indicator	ID	1/1	114	R	P or T (See below for more details)
		Element Separator	AN	1			*
	ISA16	Component Element Separator		1/1	115	R	: (semi colon). this value must be different than the data element separator and the segment terminator
		Element Separator	AN	1			*

Sample:

ISA*00* *00* *ZZ*8431 *ZZ*ZIRMED *130215*1234*^*00501*000000001*1*P*:~

Important Note on the above sample:
ISA02
Since ISA is fixed length segment, even though if no values are present, we need to fill up empty spaces. Here ISA02 is filled with 10 empty spaces.

ISA04
Since ISA is fixed length segment, even though if no values are present, we need to fill up empty spaces. Here ISA04 is filled with 10 empty spaces.

ISA06
Since ISA is fixed length segment, if the value is not 15 characters length, then we need to append empty space to make 15 characters string.

ISA08
Since ISA is fixed length segment, if the value is not 15 characters length, then we need to append empty space to make 15 characters string.

Segment Structure

Sample 2
ISA*03*id27032743*01*XYXY2233 *ZZ*XX09211223 *01*030240928 *130829*1102*^*00501*290811021*0*T*:~

User Name and Password
In some clearing house, they might ask to send the user name and password along with each EDI file. That's what Authorization information Information refer ISA01, ISA02,ISA03 and ISA04. After you sign up with the clearing house, ask your user name and password to send along the EDI File if they need. In such case, ISA01 will have the value"03" , ISA02 will have the user id, ISA03 will have the value "01" and ISA04 will have the actual password. Very important, since ISA is fixed length segment, and ISA02 is 10 character, so if your user id is less than 10 characters, then you need to append empty spaces to make it as 10 character word.

Sample with the User id and Password.

Segment Structure

ISA01 - Authorization Information Qualifier
Code to identify the type of information in the Authorization Information

Code	Definition
00	No Authorization information Present(No Meaningful information in 102). Advised unless security requirements Mandate use of Additional identification information.
03	Additional Data Identification.

ISA03 - Security Information Qualifier
Code to identify the type of information in the Security information qualifier

Code	Definition
00	No Security information Present(No Meaningful information in 104). Advised unless security requirements Mandate use of password data.
01	Password

ISA05, ISA07- Interchange ID Qualifier
Code to identify the type of information in the Security information qualifier

Code	Definition
01	Duns(Dun & BradStreet)
14	Duns Plus Suffix
20	Health Industry Number (HIN)
27	Carrier Identification Number
28	Fiscal Intermediary Identification Number.
29	Medicare Provider and Supplier Identification Number
30	U.S Federal Tax Identification Number
33	National Association Of Insurance Commissioners Company Code (NAIC)
ZZ	Mutually Defined

ISA06 – Interchange Sender ID
During the sign up process with clearing house, they will assign a unique ID to the software vendor. So in the practice information setup, software should have a option to enter this value. This is mandatory for all the EDI Files, without this ID, clearing house will not be able to process the file.

ISA08 – Interchange Receiver ID
During the sign up process with clearing house, they will provide this value. Usually, this will be clearing house name. So in the practice information setup, software should have a option to enter this value. This is mandatory for all the EDI Files, without this ID, clearing house will not be able to process the file.

ISA13 – Interchange Control Number
Control Number assigned by the Sender for tracking purpose. This number must be identical to the Interchange Trailer IEA02. Ever time
when creating the EDI File, software can generate a unique number to identify the batch for later case to track.

ISA14 - Acknowledgment Requested.

Code	Definition
0	No Acknowledgment Requested
1	Interchange Acknowledgement Requested

Default to 0. In some cases, if the software vendor integrated to clearing house via web services. then we can ask the clearing house to send the acknowledgment for each EDI File batches.

ISA15 – Usage Indicator.

Code	Definition
P	Production Data
T	Test Data

After the sign up process with clearing house, they will ask the software vendor to send sample files with different use cases. In such cases, all the files should be send as Test Data. So in the practice information setup, software should have this option to select. Once test files are approved, then software admin can change this value to Production.

Questions or feedback are always welcome.

X12 EDI Examples

Note : In Medical Billing, people use different words for the same thing; Here are those most commonly used;

GS – Functional Group Header

ISA – Interchange Control Header