ANSI X 12 Flashcards
ANSI
American National Standards Institute
SDO
Standards Development Organization
X12N Standards
All covered entitites must comply
Organizations sending the 277 Health Care Claim Status Response include:
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
Other businesses affiliated with 277
Billing Services
Consulting Services
Vendors of payments
EDI network intermediaries, such as automated clearinghouses, value-added network, and telecommunication services.
A transaction 277 response may include
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
Who posts a 277 Transaction
Insurance companies, intermediaries, government agencies and auditors, or billing agents and services.
Who performs the Acknowledgement
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.
278 Certification and Authorization Referral and the request for Review and Response.
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.
Events covered by 278 Transaction
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
Terms used in a 278 review transaction
Long-term care Patient Event Requester Service Provider Utilization Management Organization (UMO) or Insurer
How to issues addressed by the 278 differ from those for the 276?
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.
The 278 trading partners - unsolicitated
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.
278 Trading Partner Events
Patient arrival notice
Patient discharge notice
Certification or service change notice
Notification of certification or authorization to the primary provider, other providers, and UMOs
278 Transaction Flow for 278
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.
820-Health Plan Premium Payments
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.
820-Payment form
a transaction order to a financial institution or directions to a payee’s accounts receivable system. And/or premium paytments to an insurance carrier.
EFT
Electric Funds Transfer, transactions that are fully supported through submission of the 820.
820 Applicable transactions
Sending premium payments to:
Insurance company
Health care organization
Government Agency
Who initiates an 820 transaction
an employer or sponsor
820 and HIPAA
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.
1st HIPAA use of EFT/820
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
2nd HIPAA use of EFT/820
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
820 and Banks
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.
