Lesson 2 Preparing to Test the 837

Lesson 2 Preparing to Test the 837

Section 2 Topics • Electronic Data Interchange and Standards • What is the 837? • Software requirements • Implementation Guides • Establish relationship with insurer

Section 2: Preparing to Test the 837 • Electronic Data Interchange and Standards • What is the 837? • Software requirements • Implementation Guides • Establish relationship with insurer

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

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.”

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

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

EDI Health Care Claims Standards (cont’d) • 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

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.”

What Is the 837? (cont’d) • Current HIPAA compliant version • ANSI Standard X12N 837 Version 4010 with Addenda (004010X096A1)

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

Types of 837 Electronic Claims (cont’d) • 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

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

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

Don’t 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

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

Washington Publishing Company (cont’d) • 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

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

List of Key Basic Terms • Data element • Data segment • Control segment • Delimiter • Loop • Transaction set • Header and Trailer

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

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

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:

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

ISA* 00*..........*01* SECRET....* ZZ* SUBMITTERS.ID..* ZZ*RECEIVERS.ID...* 930602* 1253* U* 00401* 000000905* 1* T* :~ Delimiters Delimiter • Delimiter is character used to: • Separate two data elements • Terminate a segment • Delimiters are integral part of data

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

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

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

A Data Stream datadatadataaparagraphisatransactionsettheindentedlineistheheadersegmentspacesdelimitwordsperiodsdelimitsentencestheblanklineattheendisthetrailersegmentdatadatadata

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

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

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

Review

What Does It Mean For You? Compliance/Privacy Officer:“It’s forced them to put more attention on the staff.” Accounting Technician:“There was a little stage fright.” Financial Management Officer:“We’ve done all the groundwork” Assistant Site Manager:“It’s gotten easier along the way.”

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

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? Gather Important Information on Testing Process

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? 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? Gather Other Important Information

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

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

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

Companion Guide (cont’d) • Specifies insurer’s 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

Get Your Companion Guide Don’t Start Testing Without It!

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

Benefits of a TPA • Assures you are a priority to do HIPAA testing • May provide access to insurer’s online systems • Means you get paid at higher rate because you are a contract provider

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?module=compliance_packet

TPA Tips • Agreement requires signatures • Allow enough time to get all the signatures • Don’t 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

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

Lesson 2 Preparing to Test the 837