What is EDI

Electronic Data Interchange –

Transferring data Electronically from
one place to another via a secured
path.
 PART 1 Agenda
What is EDI
What is HIPAA
Types of claim transactions
X12 structure of Claim transaction
 What is HIPAA
Health Insurance Portability Accountability Act -
HIPAA, the Health Insurance Portability and
Accountability Act, was enacted by the U.S.
Congress in 1996, and became effective July 1,
1997. This act is a grouping of regulations that work
to combat waste, fraud, and abuse in health care
delivery and health insurance. The intention of the
HIPAA is also to improve the effectiveness and
efficiency of the health care system, portability and
continuity of health insurance coverage in the group
and individual markets, as well as the ability to
provide consequences to those that do not apply
with the regulations explicitly stated within the Act.
 IMPROVED HEALTHCARE DELIVERY BY STANDARDIZING THE
ELECTRONIC DATA INTERCHANGE FOR:

• PATIENT HEALTH
• ADMINISTRATIVE
• FINANCIAL
• PROTECTS HEALTH DATA CONFIDENTIALITY AND SECURITY:
• SETS AND ENFORCES STANDARDS (E.G.,UNIQUE IDENTIFIERS FOR INDIVIDUALS,
EMPLOYERS, HEALTH PLANS, AND HEALTHCARE PROVIDERS)
• SETS SECURITY STANDARDS (E.G.,PROTECTING CONFIDENTIALITY AND INTEGRITY
OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION)
 What HIPAA will accomplish

• REDUCE ADMINISTRATIVE BURDEN TO PROVIDERS AND PAYERS

• REDUCE ADMINISTRATIVE COST FOR PROVIDERS AND PAYERS (A PAPER
TRANSACTION COSTS ANYWHERE FROM $5 TO $15 COMPARED TO .$85 TO $1.25
FOR AN ELECTRONIC TRANSACTION)
• CREATE A NATIONAL STANDARD FOR ELECTRONIC TRANSACTIONS ENABLING EASIER
DATA SHARING, RECORD PORTABILITY, AND AUTOMATED BUSINESS PROCESSES
• SPEED FINANCIAL TRANSACTIONS RESULTING IN FASTER PAYMENT FOR SERVICES

COMPLIANCE: A COMPLIANCE PROGRAM IS CENTRALIZED PROCESS TO IDENTIFY

CORRECT AND PREVENT ILLEGAL CONDUCT AND TO PROMOTE HONEST, ETHICAL
BEHAVIOR IN THE DAY TO DAY OPERATIONS OF AN ORGANIZATION.
 HOW WILL COMPLIANCE BE USEFUL?

ESTABLISHING COMPLIANCE STANDARDS

ASSIGNING SENIOR MGMT OVERSIGHT
CONDUCTING EFFECTIVE TRAINING AND EDUCATION
DEVELOPING EFFECTIVE LINES OF COMMUNICATION
ENFORCING STANDARDS AND DISCIPLINE VIOLATORS
AUDITING AND MONITORING
RESPOND TO VIOLATIONS TO PREVENT FUTURE OFFENCES
 What is the Relationship
between EDI and HIPAA

The relationship between EDI and HIPAA is a

Parent child relationship. All HIPAA transactions
should be submitted via EDI.
Methods of File Transmission via
EDI

 EDI via the Internet (Web EDI)

 HL7 – World Standard
 X12 – American Standard
 What is ASC X12
ASC X12 (also known as ANSI ASC X12) is the official designation of
the U.S. national standards body for the development and maintenance
of Electronic Data Interchange (EDI) standards. The group was founded
in 1979, and is an accredited standards committee under the American
National Standards Institute (ANSI). The acronym stands for "American
National Standards Institute Accredited Standards Committee X12", with
the designation of X12 being a sequential designator assigned by ANSI
at the time of accreditation with no other significance
 Membership

Health Insurance
I need an Insurance
plan that covers
Company
my Healthcare
expenses
We have a Plan for you,
that covers majority
of your Health
Coverage

Member

The following are some

of the Plans if your
age is below 55
years
HMO, PPO, POS
 Birth of a Claim
I guess I am not
feeling well,
probably I need to HOSPITAL
go to a Hospital
or
INSTITUTION

Member
Diagnoses
X-Ray
Blood Test

Treatment
Prescription or Drugs
 Health Insurance Protocol

Health Insurance Company

Trading Partners Direct Submitters External Vendors

 Structure of X12 Envelopes
The rules for X12 envelope structure ensure the integrity
of the data and the efficiency of the information
exchange. The actual X12 message structure has
primary levels that are hierarchical. From highest to the
lowest, they are:

Interchange Envelope
Functional Group
Transaction Set
Format of EDI File
Components of X12 Envelopes
The X12 messages are all in ASCII text, with the single
exception that the BIN segment is binary. Each X12
message is made up of a combination of the following
elements:

1. Elements
2. Segments
3. Loops
 Description of the Components
Elements
 Elements are separated by delimiters. The remainder of
this section explains these elements.

Segments
 A segment is a logical grouping of data elements. In
X12, the same segment can be used for different
purposes. This means that a field’s meaning can change
based on the segment. For example:
 The NM1 segment is for any name (patient, provider,
organization, doctor)
 The DTP segment is for any date (date of birth,
discharge date, coverage period)
Loops

The largest named unit of information in a

transaction set. A loop contains logically related
segments in order to group related information.
Loops are labeled by a combination of
nominative and numeric identifiers, such as
2000 Billing/Pay‐to Provider. The numeric
portion of the label indicates it placement within
the transaction (2000), while the descriptive
name identifies its focus(Billing/Pay to Provider).
 Delimiters
In an X12 message, the various delimiters are part of the syntax, dividing up the different
elements of a message. The delimiters used in a message are defined in the interchange
control header, the outermost layer enveloping the message.
For this reason, there is flexibility in the delimiters that are used. No suggested delimiters
are recommended as part of the X12 standards, but the industry-specific implementation
guides do have recommended delimiters.

The default delimiters used by the X12 OTD Library are the same as those recommended
by the industry-specific implementation guides. The default delimiters in the X12 OTD
Library are:

 Segment terminator
~ (tilde)

 Data element separator

* (asterisk)

 Subelement (component) separator

: (colon)

 Repetition separator (version 4020 and later)

+ (plus sign)
 Interchange Envelopes (ISA/IEA)
 The Interchange Envelope, often referred to as the “outer envelope,” is the wrapper
for all the data to be sent in one transmission. It can contain multiple Functional
Groups. This characteristic means that transactions of different types can be included
in the Interchange Envelope, with each type of transaction stored in a separate
Functional Group
 The Interchange Envelope is defined by the header and trailer; the Interchange
Control Header (designated ISA) appears at the beginning, and the Interchange
Control Trailer (designated IEA) appears at the end.
 As well as enveloping one or more Functional Groups, the ISA and IEA segments
include:
 Data element separators and data segment terminator
 Identification of sender and receiver
 Control information (used to verify message was correctly received)
 Authorization and security information, if applicable
 The sequence of information transmitted is:

ISA
Optional interchange-related control segments
Actual message information, grouped by transaction type into Functional
Groups
IEA
Line Items in the Interchange Header
1. Authorization Information Qualifier
2. Security Information Qualifier
3. Interchange ID Qualifier
4. Interchange Sender ID
5. Interchange ID Qualifier
6. Interchange Receiver ID
7. Date
8. Time
9. Repetition Separator
10. Interchange Control Version Number
11. Interchange Control Number
12. Acknowledgment Requested
13. Usage Indicator
14. Sub Element Separator
Example of an Interchange Trailer (IEA)
 Functional Groups (GS/GE)

 Functional Groups, often referred to as the “inner envelope,” are

made up of one or more Transaction Sets, all of the same type,
which can be batched together into one transmission. The
Functional Group is defined by the header and trailer segments.
 The Functional Group Header (designated GS) segment appears at
the beginning, and the Functional Group Trailer (designated GE)
segment appears at the end. Many Transaction Sets can be included
in the Functional Group, but all local transactions must be of the
same type.
 Within the Functional Group, each Transaction Set is assigned a
functional identifier code, which is the first data element of the
header segment. The Transaction Sets that constitute a specific
Functional Group are identified by this functional ID code.
 Line Items in the Functional Groups
The GS segment contains:

 Functional ID code (the two-letter transaction code; for example,

PO for an 850 Purchase Order, HS for a 270 Eligibility, Coverage, or
Benefit Inquiry) to indicate the type of transaction in the Functional
Group
 Identification of sender and receiver
 Control information (the Functional Group control numbers in the
header and trailer segments must be identical)
 Date and time

The GE segment contains:

 Number of Transaction Sets included

 Group control number (originated and maintained by the sender)
 Transaction Sets (ST/SE)
Each Transaction Set also known as a transaction contains:
 Transaction Set header (designated ST)
 Transaction Set trailer (designated SE)
 Single message, enveloped within the header and footer

A Transaction Set has a three-digit code, a text title, and a two-

letter code, for example, 997, Functional Acknowledgment (FA).

The Transaction Set is composed of logically related pieces of

information grouped into units called segments. For example, one
segment used in the Transaction Set might convey the address:
city, state, postal code, and other geographical information. A
Transaction Set may contain multiple segments. For example, the
address segment might be used repeatedly to convey multiple sets
of address information
 HIPAA Companion Guides
 270 Eligibility, Coverage or Benefit Inquiry
 271 Eligibility, Coverage or Benefit Response
 276 Health Care Claim Status Request
 277 Health Care Claim Status Response
 278 Health Care Services Review Information
 820 Premium Payments
 834 Benefit Enrollment and Maintenance
 835 Health Care Claim Payment/Advice
 837 Health Care Claim
 PART 2 Agenda
CLAIM FLOW
Types of claim transactions
X12 structure of Claim transaction
 Overview of 837 Format: Functional Group ID
Classification

Transaction Types

There are three types of 837 transactions:

• Professional (004010X098) and (005010X222)‐ Used by an individual
professional or practitioner to bill for medical services
• Dental (004010X097) and (005010X224) ‐ Used by dentists to bill for
dental services
• Institutional (004010X096) and (005010X223) ‐ Used by most non‐person
entities to bill for medical and medically related services

All share the same hierarchical data structure but have internal differences
that accommodate the different billing needs of the three types. For instance,
Last visit information may only be submitted on an 837 professional claim.
Formats in which Claims can be Exchanged:

1. Paper UB92, HCFA/CMS-1500

2. EDI
3. Proprietary or Custom or Flat File
4. 5 File
5. NSF (national Standard Format)
 837 Claim Structure

 Loop 1000A Submitter Name

 Loop 1000B Receiver Name
 Loop 2000A Billing/Pay‐to Provider Hierarchical Level
Loop 2010AA Billing Provider Name
Loop 2010AB Pay to Provider Name
 Loop 2000B Subscriber Hierarchical Level
Loop 2000BA Subscriber Name
Loop 2000BB Payer Name
 Loop 2000C Patient Hierarchical level
Loop 2010CA Patent Name
 Loop 2300 Claim Level Information
Loop 2310A referring Provider name
Loop 2310B Rendering Provider name
Loop2310DService Facility Provider
Loop 2320 Other Subscriber Information
Loop 2330B Other Payer Name
 Loop 2400 Service Line Information
 Loop 2430 Line Adjudication Information for Each Payer Identified in 2330B
 SAMPLE 837 FILE
ISA*00* *00* *ZZ*133068979 *ZZ*364111640 *100928*1622*U*00401*271038125*0*T*:~
GS*HC*133068979*364111640*20100928*1622*271038125*X*004010X098A1~
ST*837*000000001~
BHT*0019*00*000000001*20100928*1622*CH~
REF*87*004010X098A1~
NM1*41*2*MULTIPLAN INC.*****46*133068979~
PER*IC*LAWRENCE HARLEY*TE*2127802286~
NM1*40*2*Health Systems Inc. HCH*****46*364111640~
HL*1**20*1~
NM1*85*1*Sqa_hoes*Test****24*121212121~
N3*1 Main St~N4*Nashua*NH*03060~
REF*G2*87898~
HL*2*1*22*0~
SBR*P*18*HLLWC BB*HLLWC BB*****12~
NM1*IL*1*Savility*MemberFour***Mr*MI*123456704~
N3*4 Jacqueline Rd Apt A~
N4*Waukesha*WI*53186~
DMG*D8*19800104*M~
REF*IG*HLLWC BB~
NM1*PR*2*MULTIPLAN*****PI*36326~
N3*One Kaiser Plaza~
N4*Oakland*CA*94612~
CLM*1009088_RCFC_01*316.5***11::1*Y*A*Y*Y*P~
REF*9A*700312665~
LX*1~
SV1*HC:38207:26:27:PC:TC*65*UN*1*81**1:2:3:4~
DTP*472*RD8*20100907-20100907~
SE*60*000000001~
GE*1*271038125~
IEA*1*271038125~
 Name Segment

EX:

NM101 ENTITY ID CODES:

•1000A Sender info(with entity type qualifier=41),

•1000B Receiver info(with entity type qualifier=40),
•2010AA Billing provider info (with entity type qualifier=85)
•2010AB Pay to provider info (with entity type qualifier=87)
•2010BA Subscriber info (with entity type qualifier=IL)
•2010BB Payer info (with entity type qualifier=PR)
•2010CA Patient info(with entity type qualifier=QC)
•2310A Attending physician info(with entity type qualifier=71) and
•2310B Rendering Provide info (with qualifier=82)
NM102 ENTITY TYPE QUALIFIER:

 ‘1’ (Person)
 ‘2’ (non person)

NM108 ID CODE QUALIFIER:

 ‘24’ (Employer identification number)

 ’34’(SSN)
 ‘XX’(NPI)
N3 Street Address Segment

N4 CITY/STATE/ZIP CODE Segment

 REF Reference Identification

EX: REF*SY*030385074~

 1D Medicaid Provider Number

 SY Social Security Number
 Y4 Agency Claim Number
 DMG Demographic Information

 DMG01 D8 Date Expressed in Format CCYYMMDD

 DMG02 Date time period
 DMG03 F/M/U Gender code
 PER SUBMITTER EDI CONTACT INFORMATION

EX: PER*IC*ANE DOE*TE*9005555555~

 PER01 IC Information Contact

 PER02 Submitter contact name
 PER03 Communication number qualifier
ED Electronic Data Interchange Access Number
EM Electronic Mail
FX Facsimile
TE Telephone
 PER04 Communication Number
 DTP Date or Time or Period

DTP434RD820041209-20041214~

 DTP01
472 Service
304 Latest Visit or Consultation
455 Last X-Ray
435 Admission
096 Discharge
 DTP02
D8 Date Expressed in Format CCYYMMDD
RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
 DTP03 Date
 BGN BEGINNING OF HIERARCHICAL TRANSACTION

BHT01 Hierarchical Structure Code

 0019 Information Source, Subscriber, Dependent
BHT02 is intended to convey the electronic transmission status of the 837 batch.
 00 Original
 18 Reissue
BHT03 Reference Identification. It is the number assigned by the originator to identify
the transaction within the originator’s business application system.
BHT04 Date
BHT05 Time
BHT06 Transaction Type Code
 CH Chargeable
 RP Reporting
 CLM Claim Segment

EX:
CLM*2745331203128112806*300***11:A:1~
CLM01: Claim Submitter's Identifier
CLM02: Monetary Amount
CLM05: Health Care Service Location Information

First Digit:
1= Hospital
7= Clinic (free standing)
8= Special facility (rural primary care facility ONLY)
Second Digit:
1= Inpatient
3= Outpatient

B: Professional or Dental Services

A: Institutional

Third Digit:
1 = New claim (new or add)
7 = Replacement of prior claim (change)
8 = Void/cancel of prior claim (delete)
 LX Service line number segment

EX:

LX01 Assigned Number

Can be repeated up to 50 times in HCFA and 999 times in UB
 HCPCS

Healthcare common procedure coding system (HCPCS). HCPCS is

divided into two principal subsystems, referred to as level I and
level II of the HCPCS.

Level I of the HCPCS is comprised of CPT (Current Procedural

Terminology), The CPT are identifying codes that are used primarily
to identify medical services and procedures furnished by physicians
and other health care professionals. , while codes are identified
using 5 numeric digits.

Level II of the HCPCS is a standardized coding system that is used

primarily to identify products, supplies, and services not included in
the CPT codes, such as ambulance services and durable medical
equipment, prosthetics, orthotics, and supplies (DMEPOS) when
used outside a physician's office. Level II codes are also referred to
as alpha-numeric codes because they consist of a single alphabetical
letter followed by 4 numeric digits
 REVENUE Codes
Revenue codes are 3-digit numbers that are used on hospital bills to tell the
insurance companies either where the patient was when they received
treatment, or what type of item a patient might have received. A medical
claim will not be paid if this is missing from a bill. Revenue codes go along
with procedure codes.

An easy example to use here would be to match up CPT Code 99282, which
is for an emergency room visit of low to moderate severity, and revenue
code 450, which stands for emergency room. In this case, revenue code
450 is the only code that could be used for this CPT code, thus making this
one easy to code.

A more complex example to use would be something like CPT 12001, which
is a simple repair of a wound on the scalp, trunk of the body, or hands and
feet. This procedure could be done in multiple places. It could be done in
the OR as part of another procedure; that would be revenue code 360. It
could be done in the emergency room; revenue code 450. It could be done
in a treatment room; that would be revenue code 761. It could be done in a
clinic; that would be revenue code 510. There are at least 3 other revenue
codes where this procedure could be performed.
 SV1 Professional Service line

EX:
SV101
01 – HC (HCPCS)
- ZZ (Mutually Defined)
02 – Procedure Code
03, 04, 05, 06 – Modifier
Modifier example: 99100 is Anesthesia procedure code and it have various modifiers.
P1 A normal healthy person
P4 A patient with severe systemic disease that is a constant threat to life
SV103
F2 – International Unit
MJ – Minutes
UN – Unit
Note: 15 Minutes = 1 Unit

SV105

23 Emergency Room – Hospital

24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility.. ETC
 SV2 Insitutional Service line

EX:

SV202
01 – HC (HCPCS)
- ZZ (Mutually Defined)
02 – Procedure Code
SV204
F2 – International Unit
DA – Days
UN – Unit
 SAMPLE 837 FILE
ISA*00* *00* *ZZ*133068979 *ZZ*364111640 *100928*1622*U*00401*271038125*0*T*:~
GS*HC*133068979*364111640*20100928*1622*271038125*X*004010X098A1~
ST*837*000000001~
BHT*0019*00*000000001*20100928*1622*CH~
REF*87*004010X098A1~
NM1*41*2*MULTIPLAN INC.*****46*133068979~
PER*IC*LAWRENCE HARLEY*TE*2127802286~
NM1*40*2*Health Systems Inc. HCH*****46*364111640~
HL*1**20*1~
NM1*85*1*Sqa_hoes*Test****24*121212121~
N3*1 Main St~N4*Nashua*NH*03060~
REF*G2*87898~HL*2*1*22*0~
HL*2*1*20*0~
SBR*P*18*HLLWC BB*HLLWC BB*****12~
NM1*IL*1*Savility*MemberFour***Mr*MI*123456704~
N3*4 Jacqueline Rd Apt A~
N4*Waukesha*WI*53186~
DMG*D8*19800104*M~
REF*IG*HLLWC BB~
NM1*PR*2*MULTIPLAN*****PI*36326~
N3*One Kaiser Plaza~
N4*Oakland*CA*94612~
CLM*1009088_RCFC_01*316.5***11::1*Y*A*Y*Y*P~
REF*9A*700312665~
LX*1~
SV1*HC:38207:26:27:PC:TC*65*UN*1*81**1:2:3:4~
DTP*472*RD8*20100907-20100907~
SE*60*000000001~
GE*1*271038125~
IEA*1*271038125~
Interchange Header:
ISA*00* *00* *ZZ*133068979 *ZZ*364111640 *100928*1622*U*00401*271038125*0*T*:~

Functional Group Header:

GS*HC*133068979*364111640*20100928*1622*271038125*X*004010X098A1~

Transaction Set Header

ST*837*000000001~

Beginning OF HIERARCHICAL TRANSACTION

BHT*0019*00*000000001*20100928*1622*CH~
REF*87*004010X098A1~

1000 A Sender information loop

NM1*41*2*MULTIPLAN INC.*****46*133068979~
PER*IC*LAWRENCE HARLEY*TE*2127802286~

1000B Receiver information Loop

NM1*40*2*Health Systems Inc. HCH*****46*364111640~

Hierarchal level
HL*1**20*1~

2010 AA Billing Provider Loop

NM1*85*1*Sqa_hoes*Test****24*121212121~
N3*1 Main St~N4*Nashua*NH*03060~
REF*G2*87898~HL*2*1*22*0~

2010AB Pay to provider

NM1*82*1*Sqa_hoes*Test****24*121212121~
N3*1 Main St~N4*Nashua*NH*03060~
REF*G2*87898~HL*2*1*22*0~
Hierarchal level
HL*2*1*21*1~

2010BA Subscriber info

SBR*P**HLLWC BB*HLLWC BB*****12~
NM1*IL*1*Savility*MemberFour***Mr*MI*123456704~
N3*4 Jacqueline Rd Apt A~
N4*Waukesha*WI*53186~
DMG*D8*19800104*M~
REF*IG*HLLWC BB~

2010BB Payer info

NM1*PR*2*MULTIPLAN*****PI*36326~
N3*One Kaiser Plaza~
N4*Oakland*CA*94612~

Hierarchal level
HL*3*2*22*0~
PAT*01~

2010CA Patient info

NM1*QC*1*Savility*Patient***Mr*MI*123456704~
N3*4 Jacqueline Rd Apt A~
N4*Waukesha*WI*53186~

2300 Claim
CLM*1009088_RCFC_01*316.5***11::1*Y*A*Y*Y*P~
REF*9A*700312665~
HI*BK:25000*BJ:25000~
2400 Service Line
LX*1~
SV1*HC:38207:26:27:PC:TC*65*UN*1*81**1:2:3:4~
DTP*472*RD8*20100907-20100907~

Transaction set trailer

SE*60*000000001~

Functional Group Trailer

GE*1*271038125~

Interchange Trailer
IEA*1*271038125~
That’s what Health Care is all
about !
Thank You !
Questions ?