In 1996, Congress enacted the Health
Insurance Portability and Accountability Act (HIPAA). Title II of this
act, the Administrative Simplification (AS) provisions, greatly
encourages the use of EDI in the Health Care Industry. The AS provisions
define the standards to be used placing the under the ANSI ASC X12N
committee.
The main EDI transaction used is the ANSI ASC X12N 837 Electronic
Medical Claim. This comes in several different versions. There is the
837P which is the professional version. This is designed for
professional medical providers. The 837I is the institutional version
and designed for hospitals and other institutions. The 837D is designed
for dental offices. The 837 DME (also known as the DMERC) is designed
for durable medical equipment providers, like prosthetics, oxygen
equipment, etc. All are very similar but have their own specific
elements. We will focus on the 837P in this article.
Generally the medical industry is
split into three main categories: patients, providers, and payers. The
patient is the party receiving the medical treatment; the provider is
the party providing the medical treatment; the payer is the party who
pays for the medical treatment. The patient and the payer can be the
same party, but generally the payer is one or more insurance companies
who pay for the patient’s medical expenses. The provider typically bills the payer for services rendered to the
patient. This is what the 837 is for.
The 837 is a very complex document and can contain billing for
multiple patients and multiple providers for a single payer. Typically,
a provider’s office includes several medical providers that see
multiple patients in any given period. They will usually do their
billing on a daily or weekly basis, creating bills for each payer
containing all the procedures performed by all the providers on all the
patients for that payer in that time period. 837’s are normally sent
one to each payer from each office for each billing period.
The 837 is arranged in loops. These loops are referred to by number when
referencing the EDI document.
