The Basics Of Healthcare EDI/EC - Ehcca PDF Free Download

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HIPAA is all about Standards! Standards for automating the businessprocess of Claims Administration Standards for the security andconfidentiality of Health InformationCreated by McLure-Moynihan Inc 2002 MMI All rights reserved.

Eliminating Paperwork A Decades-Old Quest––––––1950s First Steps1960s Tape-based standards1970s Industry-Specific Standards1980 Cross-Industry Standards1990s EDI evolves into EC2000s Stay Tuned!Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

Let’s Define Our Terms Electronic Data Interchange:– The exchange of computer-processabledata in a standardized format between twoenterprises. Electronic Commerce:– Any use of a variety of technologies thateliminate paper and substitute electronicalternatives for data collection andexchange. Options include InteractiveVoice Response, Fax, Email, Imaging,Swipe Cards and multiple Web-basedInternet tools.Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

EDI and EC: A Place for Both EDI– Standards-based data exchange - the foundation ofquality transaction processing.– System to system exchanges of highly structureddata.– HIPAA MANDATES EDI STANDARDS! Electronic Commerce:– Multiple ways to communicate unstructured data.– People-to-system or people-to-people exchanges.Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

What Standards? What is ANSI?– American National Standards Institute– Since 1917 the only source of American NationalStandards What is ASC X12– Accredited Standards Committee X12, chartered in1979– Responsible for cross-industry standards forelectronic documentsCreated by McLure-Moynihan Inc 2002 MMI All rights reserved.

EDI Standards Paper FormsPaper records use forms toorganize information.EDI uses standardtransaction sets.Healthcare Claim 837Payment & Remittance 835Invoice 810Purchase Order 850Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

composed of smaller pieces .(Segments are composed of “data elements.”)Individual NameLast NameMiddle InitialNM1*P2*1*Clinton*Hilary*R InsuredPersonFirst NameCreated by McLure-Moynihan Inc 2002 MMI All rights reserved.

How Does EDI Work?BuyerMap andTranslate toASC X12E-mail box / VAN / VPNField NamePO NumberLine Item No.Qty. OrderedUnit of Meas.Unit PriceBuyer’s P/NVendor’s P/NDelivery QtyDelivery DateST*850*0001 BEG*00*SA*XX-1234*180301*AE123X12 PER*BD*EDSMITH*TE*800-123-567 TAX*532BEG0347765SP*C*******9 FOBPO101*PP*OR*DALLAS*TX ITD*01*3*5**10**30*******PO102E N1* ST*ABC EMPLOYERPO103*9*1234567890101 N2*CORPORATE DIVISION N3*PO104100 TOON LVD. N4*PO107AGOURA HILLS*CA*98898PO109*US PO1*1*25*EA*9.5*CT*MG*XYZ-1234 PID*FSCH01****HAMMER-CLAW MA*SCH07PD*WT*10*OZ PO1*SellerMap andTranslatefrom ASC X12Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

Moving Money andRemittance Dataabc@pfizerPO462785000 unitsTrade paymentsgenerally do twothings: they transfervalue from payer topayee, and provide theremittance informationneeded to relieve therelated receivable. Let’s talk about theHIPAA payments. HIPAA claimpayments andpremium paymentsclear thru banks. Bank networks forElectronic FundsTransfer (EFT) aresecure, widely usedand familiar – likedirect deposit.Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

Fedwire vs. ACHFedwire Immediate funds transfer.Limited data carrying capability.Bank does it for you, over the counter.Expensive to send and receive.ACH Good funds arrive the day after paymentorigination.Substantial data carrying capability.You send it electronically to the bank.Inexpensive to send and receive.Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

Healthcare EC and EDI Medicare practices and procedurescreated today’s electronic claimsprocesses. Claims clearinghouses arose to meetthe mapping and editing needs ofproviders and commercial claimspayers. Medicaid’s practices and procedurescreated today’s electronic eligibilityprocesses.Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

HIPAA Standard Transactions Healthcare Claim or Encounter (837) Enrollment and Disenrollment in a HealthPlan (834) Eligibility for a Health Plan (270-271) Claim Payment and Remittance Advice (835) Premium Payments (820) Healthcare Claim Status (276-277) Referral Certification and Authorization (278) Coordination of Benefits (837)And, later Healthcare Claim Attachment (275) First Report of Injury (148)Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

HIPAA Standard TransactionsHIPAA Implementation Guidelines, to beissued when updates to the standards arepromulgated by DHHS, are the standard forpurposes of HIPAA compliance. They aresubsets of the complete standard approvedby the ANSI (American National Standardsinstitute) committee ASC X12, version 4010.HIPAA standard transmissions mustincorporate other X12 standards used formessage management in order to function incommercial software.Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

Employer/Health PlanPlan SponsorHumanResourcesBenefit Enrollment andMaintenance (834)MembershipAccountingAccounts Payment/Remittance 0)TreasuryCreated by McLure-Moynihan Inc 2002 MMI All rights reserved.

The Claims ibility Inquiry (270)VerificationFunctionEligibility Response (271)Certification Request (278)Certification Response (278)UtilizationReviewClaim/Encounter (837)BillingandCollectionsTreasuryStatus Inquiry (276)ClaimsProcessingStatus Response (277)Payment/Remittance (835)(835)BankBank(835)TreasuryCreated by McLure-Moynihan Inc 2002 MMI All rights reserved.

Where Are We Now? Claims Administration will move into themainstream of Corporate Electronic DocumentExchange.– ASC X12 and other standards bodies can help move theindustry to long sought goals of a “networked” healthcareindustry. Providers and Payers will adopt improvedSecurity practices to keep patient informationconfidential– Internet security guidelines will also allow the E-commercerevolution to find applications in healthcare.Created by McLure-Moynihan Inc 2002 MMI All rights reserved.

Let’s Define Our Terms. Electronic Data Interchange: – The exchange of computer -processable data in a standardized format between two enterprises. Electronic Commerce: – Any use of a variety of technologies that eliminate paper and substitute electronic alternatives for data collection and exchange.File Size: 1MBPage Count: 24