The HIPAA Claim Status Responder
The status of claim, whether it has been paid, rejected, pended, adjudicated or lost is of eminent importance in the commerce between a health care provider and an insurance company paying for the services of their policy holders. Providers need to be assured that they have a proper cash flow and that problems with claims are quickly identified, rectified and the claims resubmitted. That is the reason why a considerable part of the staff in a hospital or doctors office does billing. If a provider misses payment on a particular claim or has questions regarding the adjudication they will have to contact the payer and ask for the status. Traditionally this has been handled by telephone operators or voice response systems with fax back options. And all too ofter this consists of being on hold large parts of the day to get information on a particular claim. This is time consuming and pushed many doctors to the point of giving up the solo practice.
HIPAA (Health Insurance Portability and Affordability Act) was conceived to bring administrative simplification into the provider-payer relationship and was intended to lower the costs of doing business for payers and facilitate the communications between payer and provider. The HIPAA legislation of 1996 addressed this critical bottleneck of commerce and prescribes the 276/277 EDI transaction set as format for electronic transmissions of claim status requests and responses. The law prescribes this particular transaction set as a mandatory transaction, this means that covered entities have to use it when asked to in order to convey claim status information electronically. Unfortunately 12 years after the HIPAA transaction sets were mandated we have still only spotty performance by payers in their ability to produce meaningful claim status responses.
With the Affordable Care Act, aka Obama Care the CORE Phase II requirements were adopted and it has become obligatory for health plans to provider such claim status responses within seconds using SOAP or MIME communications protocol and as long as this act is not repealed we will see increasing compliance with law by payers and the need for every payer to participate in the electronic exchange of claim status information.
The HIPAA Claim Status Responder gives payers the ability to produce 277 responses to 276 requests
Here its working mechanism in short:
Together with the EDI Exchange module all EDI protocols requirements will be handled such as the Functional Acknowledgment (999), encryption and FTP transport and in conjunction with the HIPAA RealTime Server even CORE Phase II compliance and all the requirements of the ACA can be fulfilled.
Tying in a claim systems into the HIPAA Claim Status Responder for automatic responses is a straight forward job.