required to view Quick Reference Guide
This newsletter addresses the topic, Preparing to Test the 837, which
is particularly relevant for people in the Business Office. To learn
all you need about preparing for testing:
This e-mail newsletter, Preparing to Test the 837,
is the second in the series Electronic Transactions…It's
Easier Than You Think. Electronic Transactions not only
make good business sense but they are also the law. Therefore,
IHS is producing detailed and simple-to-use training materials
to help you successfully meet the requirements for HIPAA electronic
transactions and code sets. To review the previous newsletter,
Electronic Transactions series includes
an introductory newsletter and four topic newsletters:
- Preparing to Test the 837
- Testing the 837
- Reading 837 Error Reports and Making Corrections
- Testing and Posting the 835 Remittance
Before beginning to test the electronic transactions process, certain
preparations must be made.
- You must have installed the required software modifications.
- You must obtain the appropriate ASC X12N Implementation Guides
- You need to establish a relationship with your insurers, if
you don't already have one.
You may already be familiar with the term EDI. If you aren't, you
need to learn it because you will hear it often.
Electronic Data Interchange or EDI is the computer-to-computer
exchange of business data between trading partners. In EDI, information
is organized according to a specified format set by both parties.
All information contained in an EDI transaction set is, for the
most part, the same as that on a conventionally printed document.
Standards for EDI relating to health care claims are developed
and maintained by the Accredited Standards Committee (ASC)
X12. ASC X12 was chartered in 1979 by the American National
Standards Institute (ANSI) to develop uniform standards for
inter-industry electronic exchange of business transactions.
The ACS X12 Insurance Subcommittee (X12N) developed Implementation
Guides that were originally published in May 2000. These Implementation
Guides were adopted by the Secretary of the Department of
Health and Human Services for use under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). In October
2002, additional guidance was developed and Addenda to the
X12N Implementation Guides were adopted for use under HIPAA.
reduces costs, improves accuracy, and increases
- Lessens the time and costs associated with
receiving, processing, and storing documents
- Eliminates inefficiencies
- Streamlines tasks
The 837 format replaces current electronic export modes in RPMS
3rd Party Billing System. The full name of the 837 is the Health
Claims & Equivalent Encounter Information. The definition of the
837 as it appears in the 837 Implementation Guide is as follows:
"A standardized format designed to expedite the goal of achieving
a totally electronic data interchange health encounter/claims processing
and payment environment."
The current HIPAA compliant version is the ANSII Standard X12N
837 Version 4010 with Addenda (004010X096A1).
Types of 837 Electronic Claims
The 837 format encompasses four different types of electronic claim
forms. This chart highlights the differences between the four types.
|837 - Institutional
of existing UB-92
existing electronic ADA forms
Coordination of Benefits
sending claims to secondary insurers
Coordination of benefits is also called cross-over. It is the process
of determining the respective responsibilities of two or more health
plans that have some financial responsibility for a medical claim.
There are minor modifications that must be made to RPMS before
837 claims processing testing can begin. The following patches must
be obtained from OIT and installed.
Generic Interface Software (GIS)
p2 & p5 (Optional)
Institutional, Professional and Dental Claim Requests
Billing, v2.5, p6
Tested and certified
by many different insurers. For
more information, contact the OIT Help Desk.
v98.1, Patch 13
* Contact OIT Help Desk
to verify that these are the most current releases.
What is an Implementation Guide?
Implementation Guides are the main support tool for interpreting
electronic transactions - in this case the 837. As mentioned
above, the ACS X12 Insurance Subcommittee
(X12N) developed Implementation Guides for the standards for
health care electronic transactions. The X12N HIPAA
Implementation Guides and Addenda should be your primary reference
837 Implementation Guides and Addenda
- 837: HIPAA Claim: Dental
- 837: HIPAA Claim: Institutional
- 837: HIPAA Claim: Professional
How do you get an Implementation Guide?
Washington Publishing Company publishes the output from the
Insurance Subcommittee, X12N. All X12N Implementation Guides
adopted for use under HIPAA and their corresponding Addenda
are free when downloaded at http://www.wpc-edi.com/. If you
prefer, you can purchase a book or a CD. (See sidebar for
NOTE: The Implementation Guides and the Addenda are separate
documents. Washington Publishing Company has created combined
guides incorporating the Addenda into the Implementation Guide.
These are available for a small fee.
- Download guides at http://www.wpc-edi.com/.
Click on Products/ Publications/ PDF Download
- Order guides online or call 1-800-972-4334.
The Implementation Guides and Addenda are critical
tools. You need to have hard copies of them. Keep
them where you use them.
The Guides are long (as much as 768 pages). Download
the Guides and Addenda at a slow time and print
Become familiar with the Implementation Guides and
These are large, technical documents but you will need them.
Print out the Implementation Guides and Addenda. Become familiar
with their contents and keep them where you can find them.
For more important information about Implementation Guides
and Addenda, click
here and view slides 17-35.
The process for testing and producing electronic transactions is
not automatic. It will require commitment and effort on your part
to follow through and make it work. But it is not that complicated.
It really is "easier than you think."
Get to know the health plan or insurer.
One critical part of making it work is getting to know your insurer.
Any relationship is easier when there is good communication. Knowing
whom you will be working with and what you are trying to accomplish
together makes the road a lot smoother.
If you haven't already done so, identify the individual you will
be working with through this process and get to know him/her. You
want to be able to pick up the phone should there be a problem and
talk with the person who can work it out. This is easiest to do
if the person on the other end is someone you know.
Determine that the health plan or insurer is ready for HIPAA compliance.
Find out what their expectations are of your facility. For more
important information about getting to know the health plan or the
here and view slides 31-34.
Your insurer may require you to complete Electronic Data
Interchange (EDI) forms in order to begin testing and transmitting
electronic transactions. Each EDI form should be detailed
down to the transaction level that that you will be testing
with that insurer. The insurer will assign an EDI submitter
ID number based on the completion of these forms.
Levels of Testing
testing process occurs in two phases. You must pass
Level 1 before you can test for Level 2.
- Level 1: Verifying that your software is HIPAA
compatible and that you and the insurer can
communicate on the coding and transactions
- Level 2: Verifying that you are meeting the
insurer's coding and transaction requirements
that are not specifically determined by HIPAA.
a Companion Guide.
have a Companion Guide. This guide is the insurer's
operating guide to electronic transactions. It tells you how
to send electronic transactions so that they will pass the
testing - both Level 1 and Level 2. Level 1 testing will verify
the standard HIPAA format. Level 2 testing will test for insurer
specific data. If appropriate, you may want to ask the insurer
to provide training about their company's specific electronic
transaction requirements for your staff.
insurer has a Companion Guide,
get it and review it in depth. Ask OIT to review it. For more
important information about the Companion Guide, click
here and view slides 37-40.
Complete a Trading Partner Agreement or Business Associate
Determine if your health plan or insurer has a Trading Partner
Agreement (TPA) or a Business Associate Agreement (BAA). If so,
request a copy and begin obtaining the necessary signatures. Allow
plenty of time for signature completion. To complete the agreement,
you must get a trading partner identification number from your insurer.
NOTE: Don't complete this agreement until you are ready to begin
testing. The agreement may stipulate dates for beginning or completing
For more important information about TPAs and BAAs, click
here and view slides 46-49. Click here for sample
Guides and Addenda
IHS tracks the testing status of business transactions. To see
the current testing status, click
This newsletter is one in a series of six on the topic "Electronic Transactions . . . It's Easier Than You Think." Each of the newsletters is associated with a PowerPoint presentation expands on the contents of the newsletter in a format that supports self-paced or group training. Even greater technical detail is presented in two Quick Reference Guides: "Working with the 837 Transaction" and "Working with the 835 Remittance Advice." Electronic versions of these materials are available on the IHS Electronic Transactions website at www.ihs.gov/AdminMngrResources/HIPAA/index.cfm. A training resources binder includes printed copies of these materials and a CD-ROM with electronic copies of the files.