Veterans Health Administration EDI

Veterans Health Administration EDI (HIPAA) Requirements

Veterans Health Administration EDI Billing provides the VHA with the capability to submit Institutional and Professional claims electronically as 837 Health Care Claim transmissions, rather than printing and mailing claims from each facility.

In 1996, Congress passed into law the Health Insurance Portability and Accountability Act (HIPAA). This Act directs the federal government to adopt national electronic standards for automated transfer of certain healthcare data between healthcare payers, plans, and providers.

Now that these standards are in place, the Veterans Health Administration (VHA) will submit claims containing the required standard data content to all payers accepting electronic data interchange (EDI). The overall patient billing revenue process for the VHA is summarized below (phases):

  • Intake
  • Utilization Review
  • Billing
  • Collection
  • Utilization Review

During the Intake phase, the patient is registered. Insurance information is identified and/or verified. In the Utilization Review phase, the patient is pre-certified and certified, and continued stay reviews are performed. In the Billing phase, the patient encounter is documented and coded. An electronic data interchange (EDI) bill and/or Medicare Remittance Advice (MRA) request is generated and sent to the payer. Claim status messages include information that appears on the Claims Status Awaiting Resolution (CSA) report. During the Collections phase, establishment of receivables, accounts receivables follow-up, lockbox, and any collection correspondence take place. Another Utilization Review can take place if there are any appeals.

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

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