HIPAA Claims

Non-Standard Claims Converted to Standard Claims (HealthLink)

If the HealthLink Document Control Number (DCN) begins with an “E”, HealthLink received the claim electronically from a provider. If the HealthLink DCN starts with any other character, the claim was received on paper (or manually).

Professional and institutional claims which can be scanned and via imaging made into an electronic claim are handled in this manner, so that payors can receive the majority of claims electronically. HealthLink scans and uses OCR for both professional and institutional claims types, by the use of a front-end scanning-EDI vendor.

Paper Claims (Manual Claims)

HealthLink will continue to receive paper (manual) claim submissions from providers. In order to submit as many HIPAA compliant electronic claim transactions as possible, HealthLink will make every effort possible to convert the paper (manual) claims into a HIPAA compliant claim for transmission to payors. Paper (manual) claims typically don’t have all of the necessary data elements present to be converted into a HIPAA compliant 837 claim. However, a number of these claims have enough “essential” data elements that, if combined with default populated “UNKNOWN” data, can be converted into a HIPAA complaint transaction. By doing this, HealthLink can provide a much higher level of HIPAA compliant transactions to payors.

Under certain circumstances, claims cannot be translated without affecting the validity of the claims. In these instances, HealthLink will not convert the claims into the 837 format. Examples include (but are not limited to) for professional claim types:

  • If Box 11D (is there another health benefit plan?) = “yes” and/or if Box 9 is populated
  • If Box 15 (If patient has had same or similar illness) is populated
  • If Box 16 (Dates Patient Unable to Work in Current Occupation) is populated
  • If Box 18 (Hospitalization Dates Related to Current Services) is populated
  • If Box 20 (Outside Lab) is populated If Box 22 (Medicaid Resubmission Code) is populated.

To learn more about HIPAA EDI and become a certified EDI Professional, please visit our course schedule page.

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