837 guides

837 Guides – HIPAA Compliance and Timing

837 Guides described below concern HIPAA agreement and processing time. Find general information about 837 transaction here and more specific notes about mapping practice in the earlier post.

Health Care providers with 25 or more full time employees must submit claims electronically using the 837 transaction set. HIPAA 837 Guides mandate that electronic claim submission must be compliant with the currently approved version of the 837 Healthcare Claim specification manual and 837 Guides. Provider of Service must also be established as a Trading Partner and have specific Trade Agreements with the Insurance Company in addition to the capabilities of sending a HIPAA compliant file with accordance to 837 Guides.

HIPAA does mandate that Insurance Companies must be able to receive compliant 837 Claims. Providers must establish Trading Partner agreements with those who wish to send 837 Claims. This includes Providers of Service, Billing Agencies, Clearing Houses and other Third Party vendors. A trade agreement for the 837 transactions must also be finalized before submissions begin.

Most Insurance Companies have deadlines in which 837 Claims must be received by in order to be considered for same say processing. If received after the deadline, the 837 Claims are held until the next business day’s processing. A Provider of Service should be familiar with the Insurance Company’s system availability.

A Provider of Service should also plan to send 837 claims on a schedule that coincides with their offices workflow. For example, if accounts receivable is reconciled weekly then the submission of 837 Claims should also be weekly. This allows for a higher success rate claim submission and account posting. A best practice would be to submit 837 Claims no later than 30 days. Almost all Insurance Companies have timely filing limits in which a predetermined time, for example 60 days, shall not pass from date the service and the receipt date of the Insurance Company.

How to implement HIPAA EDI succesfully?

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