Health industry EDI

Health industry EDI non-medical related code sets as an integral part of electronic transactions

Health industry EDI code sets include any set of codes used for encoding data elements. Examples: tables of terms, medical concepts, medical diagnosis, or medical procedure codes. They are used in Health industry EDI to describe various health care services, procedures, tests, supplies, drugs, patient diagnoses. Also they are used to present many administrative activities. Today’s post presents non-medical code sets for Health industry EDI.

Under HIPAA, code sets that characterize a general administrative situation, rather than a medical condition or service, are referred to as non-clinical or non-medical code sets. State abbreviations, zip codes, telephone area codes and race and ethnicity codes are examples of general administrative nonmedical code sets. Other non-medical code sets are more comprehensive. For example, the following non-medical codes describe provider areas of specialization, payment policies, the status of claims and why claims were denied or adjusted in Health industry EDI.

Provider taxonomy codes

Taxonomy codes are a standard administrative code set for identifying the provider type and area of specialization for all health care providers. Currently, many of the provider identifiers being used identify the specialty being billed on professional claims. When the provider identifier is adopted, this pecialty information will no longer be embedded into the provider identifiers. For this reason, taxonomy codes are situational data elements. Your health plan may, or may not, require taxonomy codes on both institutional and professional claims. However, they are required on claims when the taxonomy code information is necessary for a health plan to adjudicate a claim.

Claim adjustment reason codes

Many health plans send providers local “Explanation of Benefits” (EOB) codes that explain payment policies that impact reimbursement. HIPAA requires that local claim adjustment codes be replaced with standard claim adjustment reason codes. These codes communicate why a claim or service line was “adjusted” (or paid differently than it was billed) and are used in the Health Care Claim Payment/Advice (835).

Remittance advice remark codes

Remark codes add greater specificity to an adjustment reason code. For example, if the remittance advice used an adjustment reason code of 16 (claim/service lacks information which is needed for adjudication) additional information can be supplied by adding a remark code such as M24 (the claim must indicate the number of doses per vial.)

Claim status category codes

Claim Status Category codes are used in the Health Care Claim Status Response (277) transaction. They indicate the general payment status of the claim. For example, whether it has been received, pended, or paid. Examples of claim status category codes are:

P3 – Pending/Requested Information: The claim or encounter is waiting for information that has already been requested.
F2 – Finalized/Denial– The claim/line has been denied.
R3 – Requests for additional Information/Claim/Line-Requests for information that could normally be submitted on a claim.

Claim status codes

Claim Status codes are used in the Health Care Claim Status Response (277) transaction. They provide more detail about the status communicated in the general Claim Status Category Codes. For example:

2- Entity not approved as an electronic submitter.
4- Special handling required at health plan site.
5–Duplicate of a previously processed claim/line.

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