mame-masterex inc ba healthcare claims process

7/31/2019 Mame-Masterex Inc BA Healthcare Claims Process

1/20

BY:

Mame Minkah


2/20

HIPAA

EDI

Transactions Sets

Healthcare Claim Process

837

835

Structure of EDI

Major Loops

NASCO Example

2


3/20

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


4/20

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.

4


5/20

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


6/20

Provider Payer Sponsor

6

File Claim

Enroll in healthcarebenefits plan

Payment &remittance Advice

Benefit inquiry &

response

Status request& response

270271

837

276277

834

835


7/20


8/20

837 Healthcare claims transaction sets

Institutional - ASC X12N 837 (004010X096A1) - 222

Dental - ASC X12N 837 (004010X097A1) - 223

Professional - ASC X12N 837 (004010X098A1) - 224

8


9/20

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)


10/20

Subscriber orPatient

Provider-Institutional

-Professional-Dental

Payer

Clearing Houses837/Counter

837 /Counter


11/20

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.

11


12/20

Provider Payer Sponsor

12

837

834

835

270

271

276

277

Professional98A1 (224)

Dental97A1 (223)

Institutional96A1 (222)

999 - Acknowledgement Transaction Set


13/20

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


14/20

ISA GS ST actual data SE GE IEA

Contains addresses ofsender and receiver

Contains departmentaladdress information

Marks beginning ofthe actual transaction,shows transaction type


15/20


16/20

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


17/20

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


18/20

Header

Payer Loop ID 1000A

Payee Loop ID 1000B ? Loop ID 2000

Claim Loop ID 2100A

Service Line Loop ID 2110

Trailer


19/20

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


20/20

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

20

BCR Verify CSR Develop Validate

Benefit Change Request

Change System Request

mame-masterex inc ba healthcare claims process

Documents