The document provides an overview of preparing for 837 electronic claim testing, including understanding key concepts like EDI standards, the 837 transaction format, software requirements, implementation guides, and establishing relationships with payers. It emphasizes obtaining implementation guides and a payer's companion guide, communicating with payers to understand testing processes, and completing necessary agreements like trading partner agreements.

1. Section 2 837: Preparation for Testing

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

3. Section 2 837: Preparation for Testing Electronic Data Interchange and Standards What is the 837? Software requirements Implementation Guides Establish relationship with payer

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 set is same as information on conventionally printed document

5. 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

6. 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

7. EDI Health Care Claims Standards (cont’d) ACS 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

8. Section 2 837: Preparation for Testing Electronic Data Interchange and Standards What is the 837? Software requirements Implementation Guides Establish relationship with payer

9. What Is the 837? 837 format replaces current electronic export modes in RPMS 3P 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.”

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

11. 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

12. Types of 837 Electronic Claims (cont’d) 837 – Coordination of Benefits Called 837 – COB Used for sending claims to secondary payers 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

13. Section 2 837: Preparation for Testing Electronic Data Interchange and Standards What is the 837? Software requirements Implementation Guides Establish relationship with payer

14. Software Requirements: Install RPMS Patches GIS v3.01, p2 & p5 (Optional) 3 rd Party Billing, v2.5, p6 Tested and certified by many different payers 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

15. Section 2 837: Preparation for Testing Electronic Data Interchange and Standards What is the 837? Software requirements Implementation Guides Establish relationship with payer

16. Implementation Guides 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

17. 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

18. 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

19. 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

20. 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 payers

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

22. Data Element Data element corresponds to a data field in data processing terminology Data element is smallest named item in ASC X12 standard ISA * 00* ..........* 01 * SECRET.... * ZZ * SUBMITTERS.ID.. * ZZ * RECEIVERS.ID... * 930602 * 1253 * U * 00401 * 000000905 * 1 * T * :~ Data elements

23. 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

24. 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: ISA * 00* ..........* 01 * SECRET.... * ZZ * SUBMITTERS.ID.. * ZZ * RECEIVERS.ID... * 930602 * 1253 * U * 00401 * 000000905 * 1 * T * :~

25. 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

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

27. 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, payer

28. 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 payer is considered a transaction set Sequence of data segments within one transaction set is specified by ASC X12 standard

29. 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

30. Review

31. Section 2 837: Preparation for Testing Electronic Data Interchange and Standards What is the 837? Software requirements Implementation Guides Establish relationship with payer

32. Get to Know Health Plans and Payers Open communication channels Identify person you will be working with Establish relationship with that person Determine that health plan/payer is ready for HIPAA compliance If so, determine what their expectations are of your facility

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

34. Gather Other Important Information Will software be certified or will payer require each site to test individually? Will payer allow parallel testing or will they require a “hard switch”? Will payer continue to support software or systems provided by payer to conduct transactions? Does payer have a Companion Guide that must be reviewed by facility and OIT? Does payer have a Trading Partner Agreement that must be submitted? Is there an EDI (Electronic Data Interchange) form that must be submitted?

35. Companion Guide Payer’s operating guide to electronic transactions Specifies how HIPAA compliance testing and certification are to be accomplished Transmission methods Volume Timelines

36. Companion Guide (cont’d) Specifies payer’s coding and transaction requirements that are not specifically determined by HIPAA Payer may not require data elements for all fields Payer may include data elements that are specific to payer , e.g., local codes

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

38. TPA and BAA Agreements that formalize relationships with entities or persons with whom you will be doing HIPPA compliance testing and production Trading Partner Agreement (TPA) is established with external entity or payer (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 behalf of covered entity but is not part of entity’s workforce (e.g., need an example ).

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

40. Contents of a TPA What does payer cover? Which procedures are billable or not? Who is covered, who is not? Is preauthorization required? For what?

41. 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 Payer will stipulate effective date and you must begin testing within six months of that date To complete the TPA, you must obtain trading partner ID number from payer

42. Lessons Learned Obtain and install required software patches Obtain all 837 Implementation Guides and Addenda Contact health plan/payer Obtain and review Companion Guide Complete and submit Trading Partner Agreement