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.

EDITransactions 


image

      
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



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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EDI 270–5010 Documentation - ISA – Interchange Control Header

 

            

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

image


  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  

image



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  
image



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.


EDI 270 - 5010 Health Care Eligibility/Benefit Inquiry


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. EDI Instruction

Introduction

For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed and need to be implemented consistently by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.
Providers of medical services must currently submit health care eligibility and benefit inquiries in a variety of methods, either on paper, via phone, or electronically. The information requirements vary depending upon:

  • type of insurance plan
  • type of service performed
  • where the service is performed
  • where the inquiry is initiated
  • where the inquiry is sent

  • The Health Care Coverage, Eligibility, and Benefit transactions are designed so that inquiry submitters (information receivers) can determine (a) whether an information source organization (e.g., payer, employer, HMO) has a particular subscriber or dependent on file, and (b) the health care eligibility and/or benefit information about that subscriber and/or dependent(s). The data available through these transaction sets is used to verify an individual’s eligibility and benefits, but cannot provide a history of benefit use.
    The purpose of this implementation guide is to explain the developers’ intent when the Health Care Eligibility, Coverage, or Benefit Inquiry (270) and Health Care Eligibility, Coverage, or Benefit Information (271) transaction sets were designed and to give guidance on how they should be implemented in the health care industry. Specifically, this guide defines where data is put and when it is included for the ANSI ASC X12.281 and X12.282 transaction sets for the purpose of conveying health care eligibility and benefit information.

    This paired transaction set is comprised of two transactions: the 270, which is used to request (inquire) information, and the 271, which is used to respond with coverage, eligibility, and benefit information. The official names for these transactions are:

    ANSI ASC X12.281 - Eligibility, Coverage, or Benefit Inquiry (270)
    ANSI ASC X12.282 - Eligibility, Coverage, or Benefit Information (271)


    The 270 document typically includes the following:

  • Details of the sender of the inquiry (name and contact information of the information receiver)
  • Name of the recipient of the inquiry (the information source)
  • Details of the plan subscriber about to the inquiry is referring
  • Description of eligibility or benefit information requested

  • The ASC X12N Specification  - 5010 Version

     1. EDI 270–5010 Documentation - ISA – Interchange Control Header
     2. EDI 270–5010 Documentation – GS – Functional Group Header
     3. EDI 270–5010 Documentation – ST – Transaction Set Header
     4. EDI 270–5010 Documentation – BHT – Beginning Of Hierarchical Transaction
     5 EDI 270–5010 Documentation – HL – Hierarchical Level
     6. EDI 270–5010 Documentation–2100A Information Source Name
     7. EDI 270–5010 Documentation–2000B Information Receiver Level
     8. EDI 270–5010 Documentation–2000B Information Receiver Name
     9. EDI 270 – 5010 Documentation-2000C Hierarchical Level
    10. EDI 270 – 5010 Documentation – Subscriber Trace Number
    11. EDI 270 – 5010 Documentation –  2100C SUBSCRIBER Name

    Create an account in our Nagata EDI Tool and check  HIPAA X12 EDI Transactions sets.
    Here is the demo link

    EDI   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

    Sample EDI 270 5010. For clear understanding, line separator are used between loops

    ISA*03*id27032743*01*XYXY2233  *ZZ*XX09211223     *01*030240928      *130829*1102*^*00501*290811021*0*T*:~
    GS*HS*XX09211223*030240928*20130829*1102*1*X*005010X279A1~
    ST*270*0001*005010X279A1~
    BHT*0022*13*0001*20130829*1102~
    HL*1**20*1~
    NM1*PR*2*FLORIDA BLUE*****PI*BCBSF~
    HL*2*1*21*1~
    NM1*1P*2*Bella Vista Health Center*****XX*1306849724~
    HL*3*2*22*0~
    TRN*1*290811021*3030240928~
    NM1*IL*1*MULLIN*DANIEL****MI*XJBH12345678~
    DMG*D8*19571112~
    DTP*291*D8*20130829~
    EQ*30~
    SE*13*0001~
    GE*1*1~
    IEA*1*290811021~


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

    RESTful Java Web Services wrote in java which takes JSON File as input and gives you the actual EDI Message.

    Demo

     
    In your EMR/PMS software, if you need to parse the EDI 271 Response, You can use our API Service which will parse and returns as Human Readable Text. Please contact me via email vbsenthilinnet@gmail.com  for more details

    I’ve developed Web API in which you can pass the EDI 271 Message and API will return the Human Readable Text.

    These RESTful Web Services are developed using Spring Boot.

    The following video demo explain how to Make restful web service API for the service.

    Parse 271 Message to Text

    Enter video caption here



    In order to test all the RESTful Web Services , an testing tool also developed and here is the video demo for the same.

    Parse EDI 271


    Parse 271 Message to JSON Format

    Enter video caption here

    Parse 271 Message to HTML
    Parse 271 Message to HTML



    Workflow

    1) Patient Books an appointment.
    2) Billing team before the appointment date, check the Patient Insurance Eligibility.
    3) Software prepares the EDI 270 Message and send to the Payer via Clearing House entity, Payer in turn returns the Response in EDI 271 Message.  Here clearing house is the middle man between Health care Organization and Payer
    4) Software parse EDI 271 Message  and convert into Human Human Readable Text and show to application End User


    Another Example for EDI 270 and 271

    1. Provider Smith uses ABC Billing Software.
    2. Provider Smith already signed up with XYZ Clearing House and an ID has been assigned to Provider Smith by the clearing house.
    3. ABC Billing software has the option of generating EDI 270 message and through web service call, it will send the message to the clearing house.
    4. XYZ receives message within few seconds and then identify the message for Payer GOLD. Since XYZ already enrolled with the Payer Gold, so it just forward the message to Payer Gold via web service.
    5. Payer Gold receives the message and prepare the response 271 and send back to the clearing house. Immediately clearing house forward the response to the Provider Smith’s ABC billing software.


    270, 271 healthcare transactions background information

    The eligibility 270 Request and 271 Response is the third most utilized transactions in the healthcare industry, after claims submission and remittance advice transactions. Mandates from the Department of Health and Human Services requiring claim and remittance adoption were contributing factors to claim and remit transaction levels less the 270/271 could be the predominate healthcare EDI transaction. Before the 270/271 transactions were adopted, most eligibility verification was handled over the phone. Since the Healthcare 270/271 has been made a standard industry wide, Providers of Service can send the 270 Request to all Insurance Companies and expect to receive the same uniformed 271 Response format across the board.


    For Source code or Medical Billing Software Consultation, please contact me at vbsenthilinnet@gmail.com

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    Electronic Claim Submission

    We know that "Medical Billing is a Process of Submission of Bills/Claims to the Insurance Company in a specified format for the service rendered (for the treatment given) by the doctor for the patient."  And also we know that the most widely used form is Health Care Finance Admin-1500 designed by the Health Care Financing Administration (CMS 1500 or HCFA 1500).

    But instead of Sending in Paper form, We can also use Electronic transmission of claims. Here are the advantages sending the claim electronically instead of paper claims.

    1. Electronic Submission of Claims (Electronic Data Interchange or EDI) can help reduce paperwork, eliminate printing and mailing expenses, and improve claim   payment accuracy.

    2. No concerns of claims being lost in transit, no concerns regarding data entry errors being made by insurance staff while processing claims, less rejections,   less turnaround time between the process of data and process of claim by the insurance company.

    3. When you file an electronic claim, you also save valuable time. When a paper claim is filed, the U.S. mail may take a few days to deliver the claim. The  insurance company must digitize the information, then it must process the claim and, finally, the company has to mail the statement and reimbursement    back to you. With electronic claims, you send the claim through Internet connection. This takes as much time as picking up the telephone and calling the  company. The insurance carrier instantly receives the claim, the claim is already digitized and the company can process the claim immediately.

    Now you may ask a  question, since Electronic claim transmission is acceptable and useful, then why do we need still to use CMS 1500 to send the claims.The answer is : we cannot completely wipe off the Paper format, because there are some scenario, you need to send only by paper claims. We will see later about that scenario

            

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    Medical Billing–Patient Insurance

    Patient Insurance

    We know that, patient has to give his insurance information to the Doctor before the treatment. Collecting the patient insurance information is very important data entry part to avoid delayed or denials.

    Either at the time of appointment or at the time of patient visit the practice(Check in), patient insurance information has to be collected. If it is existing patient, then we need to verify the existing patient insurance information which is already in the file(or computer system).

    Very Important. For New Patient, we need to collect signed copy of HIPAA consent form. For more details, please check here.

    The following information has to collect from the patient

    1. Insurance Company Name

    2. Policy No (Unique number to identify the patient within the insurance system)

    3. Policy Group No (Identifies in which plan the patient enrolled with the insurance company)

    4. Effective Date (From which date, benefits or covered services are allowed)

    5. Relationship to the Patient(Patient may have the insurance on his name, or he/she may be covered by one of the family member)

    6. Insured details such as first name, last name, etc if the patient is not the same as insurer.

    7. Copay and deductible amount

    And also, we need to scan the patient insurance card back and front part into the system. Sample Insurance card here.

    clip_image002

    clip_image003

    clip_image005

    clip_image006

            

    Different format of Medical Forms

     

    In the last section, we said submission of claims to the insurance company in a specified format. Let us see some important format as follows

    1.  HCFA(Health Care Financing Administration)  1500 form or CMS(Centers for Medicare and Medicaid Services) form.
    It is a standard form that non-institutional providers use such as your family doctor or specialist used send claims. Mostly individual
    Physician charges are billed on the CMS 1500 form

    2.  UB-04( uniform institutional billing claim form) Form (formerly UB-92 OR CMS-1450)
    This form is used to submit claims for institutional providers such as hospitals. Some insurance accepts CMS 1500 form to submit  hospital billing. You should always check the insurance company which form they prefer to bill hospital charges.

    You can see sample CMS 1500 and UB04 Form here

            

    Sample CMS 1500 and UB04 Form

    CMS 1500 Blank Form

    CMS1500805

    CMS 1500 Sample Filled Form
    image

    Sample UB04 Form

    UB04_Red


    eClaimManager Practice Management System.  For subscription, please contact vbsenthilinnet@gmail.com

    Preview CMS 1500 Form



    Nagata EDI Tool :  Create CMS 1500 Form using  EDI 837 Professional




    EDI RESTful Web Service API

    1. JSON to EDI 837 Professional Claims
    2. Parse EDI 837p Message into JSON
    3. Parse EDI 835 Message into JSON
    4. JSON to cms 1500 Form

    Medical Billing Process

    Medical Billing is a Process of Submission of Bills/Claims to the Insurance Company in a specified format for the service rendered (for the treatment given) by the doctor for the patient. Why the doctors approach the insurance company for the payment? Since the Majority of patients has insurance coverage and details of such coverage are provided to the doctor before the treatment. So it is the responsibility of the doctor to send the claims to the insurance company and get paid for the treatment given.

    Here is the overall medical billing process. In the later section, we will see more detail on each section.

    image

    Insurance Verification:
    Process started from here and usually front desk people are doing this process. Its a process of verifying the patients insurance is active or inactive by calling insurance or through online verification. If the insurance is inactive, it does not make any sense to send the claim/bill to the insurance company to get paid. So the front office people have to make sure that patient insurance is active even before the patient appointment. If the insurance is not active, then they have to collect the fee from the patient itself(In medical billing, this normally called as Self Pay claim or Patient Responsibility claim).

    Charge Entry:
    Charge entry is nothing preparing the claim to be sent to the insurance company. After getting the treatment details and patient disease details from the doctor, the billing department will start preparing the claim.The claim details, that are needed to get your insurance claims processed are entered here, and includes, the face sheet of the patient, doctor details, information about the insurance coverage of the patient and billing information.

    Payment Posting:
    Payment posting is simply posting payments from the insurance company into the system. The insurance company sends a check along with an Statement(This is statement is called as Explanation of benefit , shortly as EOB). On the EOB the insurance company will tell you the allowed amount and the amount they paid.

    Denial Management:
    The insurance companies reject(deny) paying claims for a number of reasons. Incomplete claim form, inconsistent patient information, etc.The insurance company indicates the reason for the denial in the Statement. Billing department will resolve those errors and again submit the claim to the insurance company.

    Here is the overall medical billing process. In the later section, we will see more detail on each section.

    image

     



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

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    Move List box item up and Down using MVVM Design Pattern

    Let us see how we can implement Moving the list box item up and down. In almost all the application, we need to change the order of the record that are displayed in the list. Say for an example, if you are defining questions for the subject/exam, then question order is very important. So this example shows how you can change the order of the question using up and down button.

    MVVM CRUD with Spring 3.1 and Hibernate 4 and ZK - Part 3

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    ZK With Spring + JPA + Hibernate Entity Manager

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    Some Button CSS In ZK

    ZK Passing Parameter between two files using MVC - Part 1.

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    This is the first of a series of articles about Passing parameter between two zul files using MVC Design pattern.This article will focus on the How to pass some arguments from one window to modal window.