ANSI X 12

Question 1

ANSI

Answer 1

American National Standards Institute

Question 2

SDO

Answer 2

Standards Development Organization

Question 3

X12N Standards

Answer 3

All covered entitites must comply

Question 4

Organizations sending the 277 Health Care Claim Status Response include:

Answer 4

Insurance Companies
Third Party Administrators (TPAS)
Service corporations
State and Federal agenices and their contractors
Plan purchasers
Any other enitty that processes health care claims

Question 5

Other businesses affiliated with 277

Answer 5

Billing Services
Consulting Services
Vendors of payments
EDI network intermediaries, such as automated clearinghouses, value-added network, and telecommunication services.

Question 6

A transaction 277 response may include

Answer 6

Accepted/rejected claim status
Claim pending-incorrect/incomplete claim or supended claim
Final: Rejected claim
Final: Denied claim
Final: Approved claim pre-payment
Final: Approved claim post-payment

Question 7

Who posts a 277 Transaction

Answer 7

Insurance companies, intermediaries, government agencies and auditors, or billing agents and services.

Question 8

Who performs the Acknowledgement

Answer 8

The Acknlowledgement is often perfomed by the ANSI 996 Functional Acknolwedgment Transaction. This transaction isn’t a HIPAA Standard. Howerver, itf commerce and effcieincy are best served by usiting it, trading partners are free to do so. However, the 997 may not be used for a function otherwise supported by an approved standard transaction such as the 277.

Question 9

278 Certification and Authorization Referral and the request for Review and Response.

Answer 9

are used to transmit referral information between providers and bettween provider and payer. They’r also used for pre-certification, concurrent review, and other utilization management information. NOTE: Referral from provider to provider is the most attractive transaction for providers.

Question 10

Events covered by 278 Transaction

Answer 10

Admisstion certification review and request and response
Health care services certification review request and response
Extend certification review request and response
Authroication of services, service levels, or service extensions

Question 11

Terms used in a 278 review transaction

Answer 11

Long-term care
Patient Event
Requester
Service Provider
Utilization Management Organization (UMO) or Insurer

Question 12

How to issues addressed by the 278 differ from those for the 276?

Answer 12

The Certiffication and Authorization of Refferrals Request for Review triggers and audit of a request for services or health care encounter and the forms, conditions, certfications, and adjudication arising from it. The requster is a provider who seeks authorization or certificaiton for a patient to recieve health care services.

Question 13

The 278 trading partners - unsolicitated

Answer 13

The 278 transaction can be used to send unsolicited information to trading partners. this data can take the form of health service review copies, authroication approval, or notification of the beginning or end of treatment.

Question 14

278 Trading Partner Events

Answer 14

Patient arrival notice
Patient discharge notice
Certification or service change notice
Notification of certification or authorization to the primary provider, other providers, and UMOs

Question 15

278 Transaction Flow for 278

Answer 15

Used to transmit information pertinent to subsrciber or patient identificaiton,demographics, treatment/diagnosis, or certification of provided or proposed services in response to a 278 health care services request for review.

Question 16

820-Health Plan Premium Payments

Answer 16

also known as the “Transaction supporting Payroll Deducted and Other Group Premium Payment for Insurance Products.” It is used to pay for insurance products (individual and group premiums), to forward remittance advice associiated with those payments, or both.

Question 17

820-Payment form

Answer 17

a transaction order to a financial institution or directions to a payee’s accounts receivable system. And/or premium paytments to an insurance carrier.

Question 18

EFT

Answer 18

Electric Funds Transfer, transactions that are fully supported through submission of the 820.

Question 19

820 Applicable transactions

Answer 19

Sending premium payments to:
Insurance company
Health care organization
Government Agency

Question 20

Who initiates an 820 transaction

Answer 20

an employer or sponsor

Question 21

820 and HIPAA

Answer 21

In 2013, the 820 transaction was formally adopted as a standard uner HIPAA for health care EFT and remittance advice (RA) transactions, with an effective implementation date of January 1, 2014.

Question 22

1st HIPAA use of EFT/820

Answer 22

with remittance information carried throughthe Automated Clearinghouse (ACH) system. The choice of which type of detail is follawed by the contract type:
Organization summary remittance detail
Individual remittance detail

Question 23

2nd HIPAA use of EFT/820

Answer 23

the use of an EFT or a check to make the premium payment, with separate remittance advice containing information for either of the following.
Organization summary remittance detail
Individual remittance detail

Question 24

820 and Banks

Answer 24

The movement of remittance advice is through 820 transaction communicated outside of the banking networks. The choid of detail detail depends on the contract.
The 820 can be sent to the bank:
To move money only
to move money as well as detailed or summary remittance information.

Question 25

820 and PAYEE

Answer 25

The 820 transaction can also be sent directly to a payee to move detailed or summary remittance information.

Question 26

Remittance Advice

Answer 26

is intended to support automatic reconciliation of premiums in a health plan’s accounts receivable systems and is one of the msot attractive transactions from a health plan’s viewpoint.

Question 27

834-Enrollement or Disenrollemnt in a Health Plan

Answer 27

the 834 transaction is used to transfer enrollment information from a sponsor to a health care insurance or benefit provider. the sponsor is the employer, associateo, or other agency that ulitmately pays for the insurance cov

Question 28

Sponsor

Answer 28

The sponsor is the employer, association, or other agency that ultimately pays for the insurance coverage. The sponsor may also elect to designate a Third Party Administrator (TPA) to submit the information.

Question 29

834 - Transfer

Answer 29

the 834 is used to transfer enrollment information from the sponosr of the health care insurance coverage, benefits, orpolicy to a health company.

Question 30

834-Use

Answer 30

This transaction is used to enroll, update, or disenroll employees and dependents in a health plan. The transaction is typically used in two modes” update and full replacement

Question 31

834-update mode

Answer 31

The employer, union, or other sponsor sends transactions to add, change, or temrinate subscriber and dependent records.

Question 32

834-Full replacement mode

Answer 32

The sponsor periodcially send a complete file of all subrsibers and dependents, and the payer does a comparison and reconciliation with its files. The enrollment transaction is expected to be popular with large accounts. Onlice screen services may be more popular with small and medium size accounts.

Question 33

834 - Parties that engage in enrollment process

Answer 33

Sponsor
Payer/insurer 
Third Party Administrator (TPA)
Subscriber
Dependent
Insured or member