Preparing to Test the 837

1

• Lesson 2
• Preparing to Test the 837

2
Section 2 Topics

• Electronic Data Interchange and Standards
• What is the 837?
• Software requirements
• Implementation Guides
• Establish relationship with insurer

3
Section 2 Preparing to Test the 837

• Electronic Data Interchange and Standards
• What is the 837?
• Software requirements
• Implementation Guides
• Establish relationship with insurer

4
What Is EDI?

• Electronic Data Interchange
• Computer-to-computer exchange of business data
  between trading partners
• In EDI, information is organized according to
  specified format set by both parties
• For the most part, all information contained in
  EDI transaction sets is same as information on
  conventionally printed documents

5
What Does It Mean For You?

• Lead Business Office Assistant Sending paper
  claims was time consuming.
• Application Coordinator And the turn-around
  could vary from 14 to 30 days.

6
Benefits of EDI

• EDI reduces costs, improves accuracy, and
  increases productivity
• Lessens time and costs associated with receiving,
  processing, and storing documents
• Eliminates inefficiencies
• Streamlines tasks

7
EDI Health Care Claims Standards

• Developed and maintained by Accredited Standards
  Committee (ASC) X12
• ASC X12 chartered in 1979 by American National
  Standards Institute (ANSI) to develop uniform
  standards for inter-industry electronic exchange
  of business transactions

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EDI Health Care Claims Standards (contd)

• ASC X12 Insurance Subcommittee (X12N) developed
  Implementation Guides originally published in May
  2000
• Implementation Guides adopted by DHHS Secretary
  for use under HIPAA
• In October 2002, additional guidance was
  developed
• Addenda to X12N Implementation Guides were
  adopted for use under HIPAA

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Section 2 Preparing to Test the 837

• Electronic Data Interchange and Standards
• What is the 837?
• Software requirements
• Implementation Guides
• Establish relationship with insurer

10
What Is the 837?

• 837 format replaces current electronic export
  modes in RPMS 3rd Party Billing System
• Full name Health Claims Equivalent Encounter
  Information
• Definition of 837 from 837 Implementation Guide
• A standardized format designed to expedite the
  goal of achieving a totally electronic data
  interchange health encounter/claims processing
  and payment environment.

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What Is the 837? (contd)

• Current HIPAA compliant version
• ANSI Standard X12N 837 Version 4010 with Addenda
  (004010X096A1)

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Types of 837 Electronic Claims

• 837 Institutional
• Called 837I replaces UB-92
• 837 Professional
• Called 837P replaces HCFA-1500
• 837 Dental
• Called 837D replaces ADA forms

13
Types of 837 Electronic Claims (contd)

• 837 Coordination of Benefits
• Called 837 COB
• Used for sending claims to secondary insurers
• Coordination of benefits also called cross-over
• Process of determining respective
  responsibilities of two or more health plans that
  have some financial responsibility for a medical
  claim

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Section 2 Preparing to Test the 837

• Electronic Data Interchange and Standards
• What is the 837?
• Software requirements
• Implementation Guides
• Establish relationship with insurer

15
Software Requirements Install RPMS Patches

• GIS v3.01, p2 p5 (Optional)
• 3rd Party Billing, v2.5, p6
• Tested and certified by many different insurers
• AUT Patch v98.1, p13
• For more information and most current releases,
  contact ITSC Help Desk
• http//www.ihs.gov/GeneralWeb/HelpCenter/Helpdesk/
  index.cfm

16
Section 2 Preparing to Test the 837

• Electronic Data Interchange and Standards
• What is the 837?
• Software requirements
• Implementation Guides
• Establish relationship with insurer

17
Implementation Guides and Addenda

• Main support tool for interpreting electronic
  transactions like the 837
• ACS X12 Insurance Subcommittee (X12N) developed
  Implementation Guides for standards for health
  care electronic transactions
• X12N HIPAA Implementation Guides and Addenda
  should be your primary reference documents

18
Dont Cut Corners

• Implementation Guides and Addenda are critical
  tools
• You need to have hard copies of them
• Each Guide is about 800 pages long so print
  Guides and Addenda double-sided
• Get them and keep them where you use them

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Washington Publishing Company

• Publishes X12N Implementation Guides and Addenda
  adopted for use under HIPAA
• Free to download
• All Implementation Guides (May 2000)
• All corresponding Addenda (October 2002)
• Can purchase
• Book or CD
• Version that integrates Addenda into
  Implementation Guide

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Washington Publishing Company (contd)

• www.wpc-edi.com
• Click on Products/Publications/PDF Download
  (Free)
• Or call 1-800-972-4334
• Three 837 Implementation Guides and Addenda
• 837 HIPAA Claim Dental
• 837 HIPAA Claim Institutional
• 837 HIPAA Claim Professional

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Understanding 837 Implementation Guides (IGs)

• Implementation Guide contains key terms
• Testing coordination staff must understand terms
• Software developers may use terms
• To assist sites
• To work with insurers

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List of Key Basic Terms

• Data element
• Data segment
• Control segment
• Delimiter
• Loop
• Transaction set
• Header and Trailer

23
Data Element

• Data element corresponds to a data field in data
  processing terminology
• Data element is smallest named item in ASC X12
  standard

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Types of Data Elements

• Mandatory data element
• Data is required to be populated or entire batch
  will not pass initial submission
• Situational data element
• Dependant upon facility
• Can be populated if data element applies

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Data Segment

• Data segment corresponds to a record in data
  processing terminology
• Data segment contains related data elements
• Sequence of data elements within one segment is
  specified by ASC X12 standard
• All of this is a data segment

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Control Segment

• Control segment has the same structure as data
  segment
• Uses
• To transfer control information (e.g., start,
  stop) rather than application information
• To group data elements

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Delimiter

• Delimiter is character used to
• Separate two data elements
• Terminate a segment
• Delimiters are integral part of data

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Loop

• Loop is group of related data segments
• Loops are specified by each Implementation Guide
• Importance of loops
• Some segments repeat
• Example address line
• Loop identifies which address it is
• Example Billing Office, subscriber, insurer

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Transaction Set

• Transaction set contains data segments
• Transaction set is a grouping of data records
• For instance, a group of benefit enrollments sent
  from sponsor to insurer is considered a
  transaction set
• Sequence of data segments within one transaction
  set is specified by ASC X12 standard

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Headers and Trailers

• Header is the start segment for transaction set
  or functional group or interchange
• Trailer is the end segment for transaction set or
  functional group or interchange
• For example, a transaction set has
• A transaction set header control segment
• One or more data segments
• A transaction set trailer control segment

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A Data Stream

• datadatadataaparagraphisatransactionsettheindente
  dlineistheheadersegmentspacesdelimitwordsperiodsde
  limitsentencestheblanklineattheendisthetrailersegm
  entdatadatadata

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Data Stream with Delimited Elements

• data data data a paragraph is a transaction set
  the indented line is the header spaces delimit
  words periods delimit sentences the blank line at
  the end is the trailer data data data

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With Delimited Elements and Segments

• data data data. A paragraph is a transaction
  set. The indented line is the header. Spaces
  delimit words. Periods delimit sentences. The
  blank line at the end is the trailer. Data data
  data

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A Data Stream with Control Segments

• data data data.
• A paragraph is a transaction set. The indented
  line is the header. Spaces delimit words. Periods
  delimit sentences. The blank line at the end is
  the trailer.
• Data data data

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Review
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What Does It Mean For You?

• Compliance/Privacy OfficerIts forced them to
  put more attention on the staff.
• Accounting TechnicianThere was a little stage
  fright.
• Financial Management OfficerWeve done all the
  groundwork
• Assistant Site ManagerIts gotten easier along
  the way.

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Section 2 Preparing to Test the 837

• Electronic Data Interchange and Standards
• What is the 837?
• Software requirements
• Implementation Guides
• Establish relationship with insurer

38
Get to Know Health Plans and Insurers

• Open communication channels
• Identify person you will be working with
• Establish relationship with that person
• Determine that health plan/insurer is ready for
  HIPAA compliance
• If so, determine what their expectations are of
  your facility

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Gather Important Information on Testing Process

• How will claims be submitted? By website or
  messaging?
• Is there a minimum number of claims to be
  included in each batch?
• How will site receive confirmation reports that
  batch has been accepted by insurer?

• In what format will Error Reports be provided?
• What is process for correcting and resubmitting
  batch files?
• What information will insurer need from site to
  ensure resubmitted batch is not a duplicate
  batch?

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Gather Other Important Information

• Does insurer have a Companion Guide that must be
  reviewed by facility and OIT?
• Does insurer have a Trading Partner Agreement
  that must be submitted?
• Is there an EDI (Electronic Data Interchange)
  form that must be submitted?

• Will software be certified or will insurer
  require each site to test individually?
• Will insurer allow parallel testing or will they
  require a hard switch?
• Will insurer continue to support software or
  systems provided by insurer to conduct
  transactions?

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Complete EDI Forms

• Insurer may require you to complete Electronic
  Data Interchange (EDI) forms in order to begin
  testing and transmitting electronic transactions
• Each EDI form should be detailed down to
  transaction level that you will be testing with
  that insurer
• Insurer will assign EDI submitter ID number based
  on completion of these forms

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Two Levels of Testing

• Testing process occurs in two phases
• You must pass Level 1 before you can test for
  Level 2
• Level 1 verifies that
• Your software is HIPAA compatible
• You and insurer can communicate on coding and
  transaction requirements that are specifically
  required by HIPAA
• Level 2 verifies that
• You are meeting insurer's coding and transaction
  requirements that are not specifically determined
  by HIPAA

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Companion Guide

• Insurers operating guide to electronic
  transactions
• Specifies how HIPAA compliance testing and
  certification are to be accomplished (Level 1)
• Transmission methods
• Volume
• Timelines

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Companion Guide (contd)

• Specifies insurers coding and transaction
  requirements that are not specifically determined
  by HIPAA (Level 2)
• Insurer may not require data elements for all
  fields
• Insurer may include data elements that are
  specific to insurer, e.g., local codes

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Get Your Companion Guide

• Dont Start Testing Without It!

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TPA and BAA

• Agreements that formalize relationships with
  entities or persons with whom you will be doing
  HIPAA compliance testing and production
• Trading Partner Agreement (TPA) is established
  with external entity or insurer (e.g.,
  Trailblazers) with whom you will be doing
  business
• Business Associate Agreement (BAA) is
  established with person or organization that
  performs function or activity on your behalf but
  is not part of your workforce

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Benefits of a TPA

• Assures you are a priority to do HIPAA testing
• May provide access to insurers online systems
• Means you get paid at higher rate because you are
  a contract provider

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Contents of a TPA

• What does insurer cover?
• Which procedures are billable or not?
• Who is covered, who is not?
• Is preauthorization required? For what?
• For sample agreements, go to
• http//www.ihs.gov/AdminMngrResources/HIPAA/index.
  cfm?modulecompliance_packet

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TPA Tips

• Agreement requires signatures
• Allow enough time to get all the signatures
• Dont complete this agreement until you are ready
  to begin testing
• Agreement may stipulate dates for beginning and
  completing testing
• To complete the TPA, you must obtain trading
  partner ID number from insurer

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Lessons Learned

• Obtain and install required software patches
• Obtain all 837 Implementation Guides and Addenda
• Contact health plan/insurer
• Obtain and review Companion Guide
• Complete and submit Trading Partner Agreement