Solutions for HealthCare EDI

HIPAA EDI 837 Claim

EDI Health Care Claim Transaction set (837) is used to submit health care claim billing information, encounter information, or both. It can be sent from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

At present, the Health Care Claim is widely sighted as a very valuable document BUT poorly implemented document. The main reasons for the poor implementation of the Health Care Claims via EDI are:

• Complexity of Implementation - As the industry uses the EDI Claim for all types of services, the document has been designed to be as flexible as possible. Flexibility also makes the document difficult to understand. The HIPAA EDI Implementation Guideline for Professional Claims is 742 pages long, for Institutional its 622 pages long and for Dental claims a paltry 440 pages long. This is not including all of the changes detailed in each insurance carrier’s Companion Guidelines and you can get a better idea of the complexity inherent in the implementation of the Claim.

• Lack of Eligibility Information – Frequently providers will send claims in without a comprehensive knowledge of the patient’s eligibility. The reason that the industry has changed radically since the inception of HIPAA and providers have not kept up. When HIPAA was first formulated, the use of Co-Pays, Deductibles and Capitation was less common. Today with the implementation of “Smorgasbord” insurance options, the idea of basing a claim on if a patient has insurance and not what services are covered and how much the patient should and insurer pay is outdated.

 

 

More Information on HealthCare Claims Solutions from SoftCare

Download the Customer Case Study "Employer Direct Health - HealthCare Claims"

 

 

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