Which is an electronic format supported for health care claims transactions?
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Payment, with information about the transfer of funds and payment processing from a health plan to a health care provider's financial institution
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For an explanation of benefits or remittance advice from a health plan to a health care provider, see the EFT and ERA: Electronic Funds Transfer and Electronic Remittance Advice Transactions Basics fact sheet. What Is an EFT? An electronic funds transfer, or EFT, is the electronic message used by health plans to order a financial institution to electronically transfer funds to a provider’s account to pay for health care services. An EFT includes information such as:
What Is an ERA? An electronic remittance advice, or ERA, is an explanation from a health plan to a provider about a claim payment. An ERA explains how a health plan has adjusted claim charges based on factors like:
Claims Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) Under HIPAA, all payers, including Medicare, are required to use claims adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) approved by X12 recognized code set maintainers, instead of proprietary codes to explain any adjustment in the claim payment. You can request new codes and revisions to existing codes. Select the “Change Request Form” option on the official Washington Publishing Company website pages for CARCs or RARCs. Requests for codes must include suggested wording for the new or revised message, and an explanation of how the message will be used and why it is needed. Additional Medicare-specific information is available in the Medicare Claims Processing Manual, (IOM Pub. 100-04) Chapter 22 - Remittance Advice. The CARC Committee reviews requests 3 times a year. The RARC Committee reviews requests 12 times a year. HIPAA Adopted Standards HHS has adopted two standards for EFT transactions:
The adopted standard for ERA transactions is ASC X12 835 TR3. For more information, see the official ASC X12N website. Health plans are required to input the X12 835 TRN Segment into Field 3 of the Addenda Record of the CCD+Addenda. The TRN Segment in the Addenda Record of the CCD+Addenda should be the same as the TRN Segment in the associated ERA that describes the payment. Using the same TRN Segment helps to match the payment to the correct remittance advice, a process called re-association. Note: The EFT standards apply only to transmissions of data over the Automated Clearing House (ACH) Network—a processing and delivery system for EFT that uses nationwide telecommunications networks. Getting paid promptly and accurately is a chief concern for many practitioners. Electronic claim submission is one tool practitioners are increasingly using to facilitate the claim reimbursement process. Practitioners are finding that transmitting insurance claims electronically to carriers managed care companies, and other health care payers can increase their practice's cash flow and help to streamline their billing operations. The trend toward greater use of electronic claims has also been prompted by the expectation that a growing number of insurers will require electronic claim submission in an effort to cut costs. Medicare payment policies have also encouraged the trend by requiring hospitals and clinics to submit all Medicare claims electronically. The shift toward electronic claims has also been prompted by the Health Insurance Portability and Accountability Act (HIPAA). In an effort to facilitate electronic exchange of health care payment information, the HIPAA Transaction Rule mandated the use of standardized formats for electronic claim transmission. Additional information about the impact of the HIPAA Transaction, Privacy and Security Rules is available in the "HIPAA compliance" section of APApractice.org. This article outlines the basics of electronic claim submission in order to help practicing psychologists learn more about — and make the transition to — this increasingly popular reimbursement option. Why Submit Claims Electronically?Filing claims electronically can offer a number of benefits, including:
How Can I Submit Electronic Claims?Many different options and providers exist for submitting claims electronically. Following are some of the basic features of full-service and self-service electronic claims: "Full-service" Electronic ClaimsFull-service electronic claims are filed on behalf of a psychologist by a third party-often a billing service. The psychologist is required only to send basic patient and service information to the billing service, which then develops and submits the claim directly to the appropriate insurer or to a health care claims clearinghouse. How much does it cost? The billing service often retains a percentage of the total claim amount as payment for its services. The percentage retained often depends on the types of services provided, and can range anywhere from 4 to 15 percent of the total claim amount. "Self-service" Electronic ClaimsSelf-service electronic claims are developed and submitted by a psychologist (or a member of the psychologist's staff) directly to a third-party payer or health care claims clearinghouse. Practitioners who submit claims to only one or two payers may opt to submit their claims directly to the individual third-party payer using proprietary software provided by the payer. However, practitioners who submit claims to many different third-party payers often find it most convenient to submit claims to a single clearinghouse, where the claims are sorted, formatted, checked for accuracy and transmitted to the appropriate payer. Options for submitting claims to a clearinghouse include:
Additional self-service claim submission options may be available for an additional cost, enabling practitioners to perform such functions as:
The self-service option is often more economical than using a full-service billing service for solo practitioners and small practices, and provides the psychologist with an additional level of control over the sensitive personal information contained in a claim. How much does it cost to submit self-service electronic claims? Pricing may be determined on a "per claim" basis, a flat fee or a combination of a regular flat fee plus per-claim fees. Pricing may also be different depending on whether claims are entered via direct data entry or a file is uploaded from practice management software. Where Can I Find an Electronic Claim Provider?Many electronic claim providers exist in the marketplace, and practitioners should choose a provider carefully based on their administrative needs and budget. It is a good idea to talk to colleagues about services they use and recommend and find out if your practice management software includes an electronic claim submission component. What is the most common method of claim transmission?Claims transmission is when claims are transferred from the care provider to the payor. In most cases, claims are first transmitted to a clearinghouse. The clearinghouse reviews and reformats medical claims before sending them to the payor. In some cases, healthcare providers send medical claims directly to a payor.
Which is the electronic or manual transmission of claims data to payers?Health Ins. Chapter 4. Which is the financial record source document used by health care providers?Encounter form: is the financial record source document used by healthcare providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. Guarantor: person responsible for paying the charges.
Which of these best describes an electronic claims clearinghouse quizlet?Which of these best describes an electronic claims clearinghouse? In discounted fee-for-service reimbursement, a participating provider can bill patients belonging to the network for the amount over the insurance contribution.
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