Critical EDI Process Terms For EDI Operations With Veterans Health Administration (VHA)
Critical EDI process terms will be useful for medical providers that are on the stage of establishing EDI partnership with VHA.
- 835 Health Care Claim Payment/Advice – The HIPAA adopted standard for electronic remittance advice to report the processing of all claim types (including retail pharmacy). The term “835” represents the data set that is sent from health plans to healthcare providers and contains detailed information about the processing of the claim. This includes payment information and reduction or rejection reasons. All health plans are required to use the same explanation of benefit codes (adjustment reason codes) and adhere to very specific reporting requirements. The term “835” is used interchangeably with Electronic Remittance Advice (ERA) and Medicare Remittance Advice (MRA).
- 837 Health Care Claim – The HIPAA adopted standard for electronic submission of hospital, outpatient and dental claims. The term “837” represents the data set that is sent from healthcare providers to insurance companies (payers). The 837 standard includes the data required for coordination of benefits and is used for primary and secondary payer claims submission. The term “837” is used interchangeably with electronic claim.
- 277 Claim Status Messages – Electronic messages returned to the VAMC providing status information on a claim from the Financial Service Center (FSC) in Austin, Texas. These messages can originate at FSC, at the payer or at the clearinghouse.
- Clearinghouse – A company that provides batch and real-time transaction processing services and connectivity to payers or providers. Transactions include insurance eligibility verification, claims submission processing, electronic remittance processing and payment posting for electronic claims.
- eClaim – A claim that is transmitted electronically to FSC from the VHA.
- EOB – An Explanation of Benefits (EOB) reports the disposition of an individual claim. Many EOBs may be contained within a single 835 ERA file.
- ePayer – Payer that accepts electronic claims from the clearinghouse.
- Fiscal Intermediary – A fiscal intermediary performs services on behalf of health-care payers. These services include claim adjudication, reimbursement and collections. Trailblazer Health Enterprises is an example of a fiscal intermediary that acts on behalf of Medicare. Trailblazer receives claims from the VA in the form of an 837 file and then adjudicates the claims to create a MRA 835 file.
- FSC – The FSC receives 837 Health Care Claim transmissions from VistA and transmits this data to the clearinghouse. FSC also receives error/informational messages and 835 Health Care Claim Payment/Advice transmissions from the clearinghouse and transmits this data to VistA.
- HIPAA – In 1996, Congress passed into law the Health Insurance Portability and Accountability Act (HIPAA). This Act is comprised of two major legislative actions: Health Insurance Reform and Administrative Simplification. The Administrative Simplification provisions of HIPAA direct the federal government to adopt national electronic standards for automated transfer of certain healthcare data between health-care payers, plans, and providers.
To learn more about HIPAA operations and become a certified EDI Professional please visit our course schedule page.