837 Healthcare Claim Implementation Guides
837 healthcare claim can be compared to an invoice in the merchandising world. However, it is much more complicated than that and some consider it to be the most complicated EDI transaction set. The purpose of this transaction is to submit healthcare billing information from providers of healthcare services to payers, either directly or via intermediary billers and claims clearinghouses. Claims can be submitted by many different entities and some of them include: physicians, hospitals, medical facilities or suppliers, dentists, and pharmacies, optometrist, chiropractors. Insurance company, health maintenance organization (HMO), preferred provider, organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups.
A thick book can be written on this topic and it still will not cover all the aspects of the healthcare claim process. That is why it is crucial to use the implementation guidelines of the trading partners when sending or receiving the healthcare claim. The healthcare claim is typically accompanied by other transactions most likely in the following order:
• 270 – Eligibility, Coverage or Benefit Inquiry issued by the provider
• 271 – Eligibility, Coverage or Benefit Response from the insurer (payer)
• 278 – Healthcare services review exchanged with provider and insurer about patient benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, amounts for coinsurance, co-pays, deductibles, exclusions and limitations.
• 837 – Healthcare Claim sent by the provider or provider’s billing party
• 276 – Healthcare Claim Status Inquiry, used by provider to receive status of 837 healthcare claim.
• 277 – Healthcare Claim Status Response to Healthcare Claim Status Inquiry
• 835 – Healthcare Claim Payment / Remittance Advice (equivalent to the paper explanation of benefits).
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