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Re: 837 Medical Claims question
Karen, I assume you are a payer or a Third Party Administrator if you
are reading others' (providers') X12 837 Healthcare claims. Further, I'm
assuming you're talking about HIPAA standard 837 Healthcare claims,
whose implementation is optional now but mandated on October 16th.
No, you will not receive any specs - or "companion" guides as they are
known in the business - from providers. Generally only payers push their
weight around by promulgating these things that supposedly clarify the
HIPAA guides, but often are nothing but a litany of special needs and
one-off requirements. The bulk of most companion guides is mostly
redundant regurgitation of what's already available in the HIPAA
implementation guide. The remainder is often illegal constraints placed
on the provider because the payer isn't able - or doesn't want - to
conform to the variations allowed by the HIPAA IG. This often forces the
provider to maintain separate maps and logic for each of his payers,
defeating the purpose of the nationally imposed "standard."
As a payer, you must be prepared to accept any provider's 837 which
complies with the HIPAA implementation guide. That means you must accept
any "situational" (subtly different from "optional") data, which is
allowed in the context of the IG; this doesn't mean you have to do
anything with the data, though. Segments and elements marked as "not
used" in the HIPAA IG are not to be used at all, and you are free to
completely ignore that data.
William J. Kammerer
Novannet, LLC.
Columbus, US-OH 43221-3859
+1 (614) 487-0320
----- Original Message -----
From: "kbrasier2003" <
To: <
Sent: Wednesday, 30 July, 2003 10:31 AM
Subject: [EDI-L] 837 Medical Claims question
I have been using EDI X12 for several years in business organizations
using po's, invoices, acknowledgements... I have just started working on
Medical claims... when i have asked our trading partners for specs on
what they are sending, 90% of the them are referring me to the 857
standard x12 format.... In the past, I have mapped each tp according to
their specs of what fields within what segments they were sending...
easy, precise.... what I am finding here is that nobody seems to have
their own specs, although some are choosing different 'optional'
segments.. I find myself having to look thru the file they have sent,
deciphering what fields are in what segments ... Some tp's are even
sending segments that according to the 837 'standard' mapping are 'not
used'... ??? is this typical of medical claims? I feel like there is
something here I am missing ... any suggestions? thanks much!
Karen
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