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BY:
Mame Minkah
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HIPAA
EDI
Transactions Sets
Healthcare Claim Process
837
835
Structure of EDI
Major Loops
NASCO Example
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HIPAA is the Health Insurance Portability andAccountability Act of 1996. A federal law that specifies thetypes of measures required to protect the security andprivacy of personally identifiable health information.
Why HIPAA?
Reduces administrative costs/ paperwork
Standardizes information
Increases efficiency and quality
Provides aggregated data
Improves privacy and security
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Electronic Data Interchange (EDI) the structured transmission of data between organizations by
electronic means from one computer system to another computersystem without human intervention.
Governed by specific standards set by ASC X12 (the AccreditedStandards Committee).
Each release contains set of message types called a Transaction.
A "transaction" is an electronic business document, identified by aspecific number e.g. healthcare claim is 837.
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Every new release contains new version number. Versionnumber examples: 4010, 4020, 4030, 5010, 5030, etc.
Major releases start with new first number. For example: 4010is one of the major releases, so is 5010. However 4020 isminor release. Minor releases contain minor changes orimprovements over major releases.
Deadline for implementing version 5010 for EDI transactionswasJanuary 1, 2012
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Provider Payer Sponsor
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File Claim
Enroll in healthcarebenefits plan
Payment &remittance Advice
Benefit inquiry &
response
Status request& response
270271
837
276277
834
835
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837 Healthcare claims transaction sets
Institutional - ASC X12N 837 (004010X096A1) - 222
Dental - ASC X12N 837 (004010X097A1) - 223
Professional - ASC X12N 837 (004010X098A1) - 224
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Batch
Typically grouped together in large quantities and processed en-masse. In a batch mode
Sender does not remain connected while the receiver processes the
transactions
Real Time Typically transactions that require an immediate response.
Sender remains connected while the receiver processes thetransaction and returns a response transaction to the originalsender. (range from a few seconds to around thirty seconds, andshould not exceed one minute)
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Subscriber orPatient
Provider-Institutional
-Professional-Dental
Payer
Clearing Houses837/Counter
837 /Counter
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The 835 is intended to meet the particular needs of thehealth care industry for the payment of claims andtransfer of remittance information. Make a payment
Send an explanation of benefits (EOB)
Or both
Claims Adjudication
refers to the determination of the insurer's payment or financialresponsibility, after the insurance benefits are applied to amedical claim.
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Provider Payer Sponsor
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837
834
835
270
271
276
277
Professional98A1 (224)
Dental97A1 (223)
Institutional96A1 (222)
999 - Acknowledgement Transaction Set
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DETAILS
Interchange Control Header ( ISA )
Functional Group Header ( GS )
Transaction Set Header ( ST )
Transaction Set Trailer ( SE )
Functional Group Trailer( GE )
Interchange Control Trailer ( IEA)
ENVELOP
ENVELOP
ENVELOP
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ISA GS ST actual data SE GE IEA
Contains addresses ofsender and receiver
Contains departmentaladdress information
Marks beginning ofthe actual transaction,shows transaction type
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Header
Submitter Loop ID 1000A
Receiver Loop ID 1000B Provider Loop ID 2000A
Subscriber Loop ID 2000B
Patient Loop ID 2000C
Claim Loop ID 2300
Service Line Loop ID 2400
Trailer
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Submitter Loop 1000A NM1 Submitter Name REF Secondary Identification N3 Submitter Address DMG Demographic Information PER - Contact Information
Subscriber Loop 2000B HL Hierarchical Level SBR - Subscriber Information PAT - Patient Information
Claim Loop 2300 CLN Claim Information REF Medical Record K3 File Information
AMT
Payer Estimated Amount17
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Header
Payer Loop ID 1000A
Payee Loop ID 1000B ? Loop ID 2000
Claim Loop ID 2100A
Service Line Loop ID 2110
Trailer
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Header
Sponsor Loop ID 1000A
Payer Loop ID 1000B Member Level Details Loop ID 2000A
Member Loop ID 2100A
Healthcare Coverage Loop ID 2300
Coordination of Benefit Loop ID 2320
Trailer
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NASCO is an integrated claims processing system usedby Blue Cross Blue Shield provides a highly configurable membership solution, and a
multitude of performance-based services designed to improve
operational efficiencies and reduce costs
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BCR Verify CSR Develop Validate
Benefit Change Request
Change System Request