Medical Claims Clearinghouse EDI Reports

  February 08, 2012       By Ray Atia
Medical Electronic Data Interchange (EDI) reports are easy to understand once the basic terminology is defined. EDI is the transmission of data from one computer system to another in a standard format. Medical Claims Clearinghouses act as a bridge between the millions of health care providers sending electronic claims to thousands of insurance carriers. Knowing the difference between Loops, 837, ANSI and PIF files will help when talking with clearinghouse customer support people. Getting Data to the Clearinghouse - EDI transmits data in file segments. A Loop is a repeated segment. Practice Management (PM) Software connected to a Medical Claims Clearinghouse automatically transmits the files. Medical EDI Reports can be received from the clearinghouse and insurance carriers through the PM Software. To submit claims on PM Software not connected with a clearinghouse will likely require a Print Image File (PIF). Information entered in the PM Software creates a PIF file which is downloaded to the desktop then uploaded to the clearinghouse. A printed PIF looks like a CMS-1500 medical claim without the background fields. Another file format that may be submitted to an insurance carrier is the ANSI file. A segment of an ANSI file including the City, State and Zip Code would look like this: *CHATSWORTH*CA*91311~ Because ANSI messages are hard to decipher, clearinghouses convert these into readable Medical Reports. The following Medical EDI Reports are available from clearinghouses: 270 Electronic Patient Eligibility (Inquiry) 271 Electronic Patient Eligibility (Response) 275 Documentation/Medical Attachment 276 Claim Status Inquiry 277 Claim Status Response • Claim on File • Was Claim Paid? • Reasons Claim is Pending Payment 278 Prior Service Authorization 820 Remittance Advice for Managed Care Organizations 834 Medicaid Enrollment for Managed Care Organizations 835 Remittance Advice (Electronic Files of Explanation of Benefits 837P Professional Health Claims (CMS-1500) 837I Institutional Health Claims (UB-04) 837D Dental Health Claims 997 Acknowledgement of Claim Status Selecting a Good Medical Clearinghouse Transferring electronic claims efficiently can save office manager hours on paper work, phone calls and correcting errors. One important consideration in choosing a clearinghouse is to find out how compatible the service is with the PM Software to be used. Check to see how easy it is to navigate the online entry screen. Also, will a regional or a national clearinghouse be needed? The right choice will provide office managers with the best medical reports.