The HIPAA Claim Status Responder
Software Solutions for the 276/277 HIPAA Transaction Sets.
The 276/277 EDI transaction set has been designated to transmit claim status information. Typically a provider would create a 276 claim status request containing the basic information on a claim that has been submitted previously. Payment of medical claims is in most cases regulated by the States by Prompt-Payment laws and insurance companies have usually only 30 days to adjudicate and pay for a claim. Still many provider offices have designated staff to find out the payment status on unpaid claims. This often consumes a lot of time and consists of hours to be spent on hold. This process lends itself for automation and the HIPAA law included this process in the list of prescribed transactions. Most payers are required by law to be able to respond to such electronic claim status requests, though there is really no enforcement yet.
The HIPAA Claim Status Responder is designed to allow payers to receive and respond to claim status requests with 277 transactions. There are two ways to create the response, manually and automatically. In manual mode the software parses the information that is contained in an X12 276 EDI Claim Status Request file and displays the request on screen and allows to enter the appropriate status. It then packages the status information into a X12 277 EDI Claim Status Response file. The manual mode of this software is designed to give HIPAA compliance in regard to the 276/277 transaction sets without a big investment and suffices for organizations that do not expect a large volume of electronic Claim Status requests.
In addition, the HIPAA Claim Status Responder can export the request information to a database. All the information is stored and the request can be reconstructed and viewed from the database record. It is now relatively easy to build an interface between your existing database which contains claim adjudication information and the HIPAA Claim Status Responder so that the responses can be created automatically. We will be available to consult on the interface construction.
The HIPAA Claim Status Responder processes files in 4010 and 5010 formats transparently. If a request comes in Version 5010, the response will be in 5010 formation while 4010 requests will be answered with 4010 responses.
The HIPAA Claim Status Responder will enable you to:
- Display the claim status request information on screen.
- EDI code sets are translated into their descriptions to show the transaction clearly and understandably.
- Choose from drop down menus the appropriate status category and status code.
- Return a simple answer or fill in all the spectrum of information that the 277 transaction set allows.
- Package multiple claim status responses into one file.
- Set a default status response that gets filled in, if you don't create a specific answer like "Claim not Found" or "No further information available".
- Edit the status codes and categories, so you will have to choose only from a subset of the hundreds of codes that HIPAA provides.
- Export of Claim Status information to any ODBC compliant database
- Tie in to existing claim system and enable automatic response (some interface development necessary)
|Fig1 shows the HIPAA Claim Status Responder with three requests listed. (Click to enlarge)|
|Each individual request can then be called up and answered. The status information and any other codes can be selected from a drop down box, so there is no possibility to enter wrong codes. The picture below shows a claim status request that has only claim level information. The status information for the same has been filled in.|
|Fig2: Answering an individual request. (Click to enlarge)|
|The 277 response file can be displayed in a printable report for easy understanding. This report can also be printed and used as an EOP.|
|Fig2: Answering an individual request .(Click to enlarge)|
|Claim status request information can be exported to any ODBC aware database such as SQL server, Oracle and MySQL. Two tables, header and detail are used for this purpose.The following picture shows the configuration screen for the database.|