Friday, 28 September 2012

Claims adjudication and payment

The Following picture demonstrates how insurance company processing the claims received from the clearing house. 

Saturday, 8 September 2012

Some Important Master screens for PMS

Last year I was involved in developing an independent system for PMS using VB6 with sql server 2005. I really enjoyed myself and love to work/complete that project. One of my best period in my life. But unfortunately, we could not able to market the product because of VB6 no longer used widely in the industry.

EDI 5010 Documentation 837 Professional - Loop 2010AA Billing Provider

2010AA Billing Provider

EDI 5010 Documentation–837 Loop 2000A - HL–Billing Provider Hierarchical Level

HL – Billing Provider Hierarchical Level

Friday, 7 September 2012

Physician Quality Reporting System - PQRS

Let me just summarized the information which i understood clearly about PQRS . The following information are taken from different websites and some of them of my own question and answer Eye rolling smile. And also I just want to have a reference about this, so that when I get chance to implement this, I can always come and refer here. At the end, I just summarized my thought on how we can implement in the EMR PMS Application.

Thursday, 6 September 2012

EDI 5010 Documentation 837 Health care claim : Professional

Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com


If you are new to Medical Billing, then please read this article
first.
If you are new to EDI, then  read the following articles

1. What is an EDI ?
2. EDI Transactions 

3. Understanding EDI Structure
4. How to Read and Understand EDI File
5. EDI Instruction
6. Beginners Guide to EDI X12 (including HIPAA)
7. What is EDI Transaction Loops and Segments?
8. Understanding EDI-Loops, Segments, and Elements

 


We will see the complete documentation on 837 with different use case sample EDI File.

837 Loops (Click each of the loop to see the complete documentation)

1. ISA Interchange Control Record
2. GS  Functional Group Header
3. ST Transaction Set Header
4. BHT Beginning Hierarchical Transaction Segment
5. LOOP 1000A Submitter Name
6. LOOP 1000B Receiver Name 
7. LOOP 2000A Billing Provider Hierarchical Level
8. LOOP 2010AA Billing Provider Name
9. LOOP 2000B Subscriber Hierarchical Level
10. LOOP 2010BA Subscriber Name
11. LOOP 2010BB Payer Name
12. LOOP 2000C  Patient Hierarchical Level
13. LOOP 2300 Claim Information
13. LOOP 2300 Date information
14. LOOP 2300 CLIA Number
15. LOOP 2300 Prior Authorization or Referral Number
16. LOOP 2300 K3 Segment
17. LOOP 2300 Health care Diagnosis Code
18. LOOP 2310A Referring Provider Name
19. LOOP 2310B Rendering Provider
20. LOOP 2310C Service Facility Location
21. LOOP 2320 Other Subscriber Information (Coordination of Benefit COB)
22. LOOP 2330A Other Subscriber Name(Coordination of Benefit COB)
23. LOOP 2330B Other Payer Name (Coordination of Benefit COB)
24. LOOP 2400 Service Line
25. LOOP 2430 Line Adjudication Info (Coordination of Benefit COB)
26. SE Transaction Set Trailer

27. GE Functional Group Trailer
28. IEA Interchange Control Trailer

 
Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com

 

EDI 837 Examples

Please note ; all these examples are tested against WPC First Pass software.

You can download trial version here.

Also, you can download the following trial version software to view/validate EDI File.

1. EDI Notepad
2. HIPPA Document Viewer 2
3. On Line Validator American Coders
4. On Line Validator EDIVance

The following open source converts X12 EDI File to XML and 1500.
OopFactory X12 Parser

The following URL discuss about other open source in EDI Software.
Comparing Open Source EDI Software

 

Download all  EDI 837 Use cases

 

Sample EDI 837 File with different use case

Use case 1
Bill with Individual NPI
Patient is same as the Insurer (Self).
Bill to Patient Primary Insurance.
No of Claims : 1
Claim No : 249
Download All files

Use case 2
Bill with Individual NPI
Patient is same as the Insurer (Self).
Bill to Patient Primary Insurance.
No of Claims : 2 (Two different patients, same primary insurance and same rendering provider )
Claim No  : 249 and 250
Download All files


Use case 3
Bill with Individual NPI
Patient is same as the Insurer (Self).
Bill to Patient Primary Insurance.
Patient is referred by another Physician (Referring Provider)
No of Claims : 1
No of Line Items : 4
Claim No : 251
Download All files

 

Use case 4
In use case 4, we will combine the above three use cases claims and make one EDI File. So this EDI File will contain  3 Claims
Download All files
 

 

Use case 5
Bill with Group  NPI
Patient is same as the Insurer (Self).
Bill to Patient Primary Insurance.
No of Claims : 1
Claim No : 252
Download All files

 

Use case 6
In this use case, we will combine all the claims created so far (use case 1 to use case 5) and we will make as one EDI File.
No Of Claims : 4
Claim No : 249, 250, 251 and 252
Download All files


 

Use case 7
Bill with Individual NPI
Patient is NOT as Same as Insurer
Bill to Patient Primary Insurance.
No of Claims : 1
Claim No : 253
Download All filess

Use case 8
Bill with Individual NPI
Patient is same as the Insurer (Self).
Bill to Patient Primary Insurance.
All Claim Level Date included :
Date Onset (431), Date Initial Treatment (454), Date Last Seen (304), Date Acute Manifestation (453), Date Accident (439), Date Last Menstrual (484), Date Last X-Ray (455), Date Last Worked(297)
No of Claims : 1
Claim No : 254
Download All files

 

Use case 9
Example for creating EDI for Secondary Insurance (Coordination of Benefits  COB Segments)
Download All files

 

Use case 10
Example for creating EDI for Secondary Insurance (Coordination of Benefits  COB Segments)
Download All files

 

Use case 11
Example for LOOP 2300 K3 Segment and CLIA Number
Download All files

 

Use case 12
Example for creating EDI for Secondary Insurance for more than one line item (Coordination of Benefits  COB Segments)
Download All files

 

Use case 13
Example for creating EDI for Tertiary (3nd) Insurance for more than one line item (Coordination of Benefits  COB Segments)
Download All files

 

Use case 14
Bulk Volume Claims 20 Claims in one EDI File
Download All files

 

You can download all use cases as one zip file here

 

Reference

 


Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com 

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com

EDI 5010 Documentation 837 Professional - Loop 1000B Receiver Name

1000B – Receiver Name