HIPAA 837 Transaction IEHP Business Scenarios (Examples) and Frequently Asked Questions
HIPAA 837 Transaction IEHP Business Scenarios described will be useful for partners Submitting HIPAA 837 Transaction to IEHP.
Example 1- IPA Submitting Institutional Encounter Data
Encounter data must be submitted by IPAs for all covered services provided to assigned Capitated members. Covered services include PCP visits as well as subcapitated services, regardless of place of service, type of service, or method of reimbursement to the provider of services. Failure to provide adequate and valid encounter data in the required format results in penalties being imposed as described in IEHP Capitated Agreement. IPAs will indicate adjudication status in loop 2300 and adjudication date in loop 2430. In accordance with CMS regulations, IEHP requires Providers to submit encounter data within ninety (90) days of each month end.
Example 2- Capitated Hospital Submitting Encounter Data
Capitated Hospitals are required to submit encounter data through the encounter data system within ninety (90) days of each month end. CMS requires IEHP to report Outpatient Medical Encounters, Inpatient Admission Encounters, Long Term Care Encounters and Pharmacy Encounters. CMS defines an Outpatient Encounter as each physician encounter, laboratory test, X-ray, therapy procedure, DME, prosthetic, orthotic, transportation, outpatient service, home health, skilled nursing, etc.
Frequently Asked Questions
Q. What is the difference between a claim file and an encounter file?
A. For the purposes of IEHP and as used in this guide, claim files are generally submitted by IEHP’s directly contracted fee-for-service providers which can include hospitals, urgent cares, and IEHP Direct providers. Encounter files are submitted by IEHP’s Capitated IPAs and Capitated Facilities. Claim files will be adjudicated by IEHP while encounter files have already been adjudicated by the IPA or facility and are primarily for data capture and regulatory reporting. Therefore, while the file format is identical, claims and encounters have different protocols for submission and likewise different internal contacts. Instructions for Claim Processing Procedures can be located in Section VI of the EDI manual while directions for Encounter Processing Procedures can be found in Section IV of the EDI manual.
Q. Where do I find information on file naming conventions, connectivity protocol, and file transfer procedures?
A. Please refer to the EDI manual published at https://ww3.iehp.org/en/providers/edi-manual/ for information regarding the above areas. The information published in this companion guide is meant to be used in conjunction with the implementation guides from Washington Publishing Company for detailed instructions on the line level and IEHP’s EDI Manual for connectivity and processing procedures.
Q. What is IEHP’s policy on Billing Provider Address and 9-Digit Zip Codes?
A. IEHP supports the instructions in the Technical Report Type 3 (TR3) implementation guides (IG) available for purchase from Washington Publishing Company http://www.wpc-edi.com regarding Billing Provider Address and 9-digit zip codes. Therefore, the Billing Provider Address (2010AA, N3) is required and must be a physical address. PO Box and lock box addresses cannot be reported as a Billing Provider Address, but can continue to be reported in the pay-to address (2010AB, N3). The 5010 requires that all used N403 segments must contain a full 9-digit zip code.