Explaining HIPAA Claims

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The HIPAA Claim Payment Master enables you to understand electronic remittance advices by translating HIPAA code sets into meaningful words. The HIPAA Claim Payment Master translates the code sets and orders the information so that you can see exactly what payments were made and which deductions taken.

The top part of the form contains:

The sender and receiver of the transaction, that is the payer who paid the claim.

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The sender and receiver information of the 835 transaction located at the top

Further, you can find the following data:

Patient information
Provider information
The claim level information
The claim line adjudication
Service line information

Summary information is displayed upfront, and each claim listed with the adjudication information and service line information structured with all the details found in the EDI file.

 

claim1835 transaction information structure

Further you can see more screen-shots of electronic remittance advices.

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The claim level information with 1 REF segment, 3 DTP segments, 1 AMT segment and 1 QTY segment

 

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Medicare Inpatient information from the MIA segment

On the following screen-shot, the Procedure Code is in the first top cell on the left. The "HC" stands for "HCPCS" codes which includes all HCPCS, ICD-9 and CPT codes. Other possible codes are "AD" for dental claims or "IV" for Home infusion codes and "N4" for NCPDP drug codes.

Adjustment Codes are translated into their descriptions, making it easy to understand the reasons behind any adjustments.

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The line level information for a claim with 3 lines

Summary information contained in TS3 and TS2 segments can extend over multiple claims. The HIPAA Claim Payment Master will begin a summary range with a bracket and then show the summary information before listing the claims.

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Beginning of the summary information block
 
Summary information is started with a bracket. At the end of a summary range is another bracket.

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End of Summary information block