EDI Process Flow At Veterans Health Administration (VHA)
EDI Process Flow above flowchart represents the path that electronic claims follow at Veterans Health Administration (VHA). The objective of electronic billing is to submit completely correct claims. Claims sent electronically reach the payer faster, are processed faster, and are paid faster than claims submitted to the payer on paper via the mail.
From the user’s desktop, the claim goes to the FSC as a VistA Mailman message. The FSC translates the claim into the HIPAA 837 Health Care Claim format and forwards it to the clearinghouse. From the clearinghouse, the arrow pointing upwards represents the path claims travel if they can be submitted electronically to the payer. If the clearinghouse does not have an electronic connection with a payer, or if specific claims must be submitted on paper, the claim is printed at Express Bill and mailed to the payers.
Electronic claims status messages from ePayers return to the VAMCs along the same path. Payers receiving printed claims do not return electronic messages. However, the clearinghouse returns a message indicating that the claim was printed and mailed. Different electronic edits are in place at each transmission point that may initiate the sending of a claims status message. Claim status messages returned by the clearinghouse and/or payer will provide information on a specific claim. There is no standard content for messages. The information contained within a claim status message varies from payer to payer.
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