About HIPAA Claim Payment Master

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Electronic Data Interchange (EDI) plays an ever increasing role in the exchange of information between healthcare providers and healthcare payers and/or clearing houses.

Most people don't know EDI when asked about it, but have an intuitive understanding when told that EDI makes ATM transactions possible. When you swipe your bank card at any ATM in the world, an EDI transaction is created in the ATM machine and sent through a network to your bank. Your bank in turn takes the ATM transaction and sends back a response EDI transaction releasing the funds to you. The banking system in the world has been working on EDI for a much longer time then the healthcare industry but we will see in our lifetime that healthcare transactions will be similarly smooth, fast and reliable.

HIPAAsuite has software applications for all 12 HIPAA mandated transactions. The HIPAA Claim Payment Master is designed to display, print and save the data of EDI X12 files that are likely to come from a payer back to the provider such as the 835 Electronic Remittance report. EDI is a very non-intuitive format and designed around computer efficiency and not human readability. Below is an example of an EDI file; you can recognize only few words in this garble. The HIPAA Claim Payment Master takes the cryptic EDI files, parses out the information, translates the codes back to English and allows one to print and display the information, so that it can be viewed, understood, interpreted and entered into an accounting system. The software can also export the payment information contained in 835 Remittance Advice files into any ODBC aware database such as Microsoft SQL Server, Microsoft Access, MySQL, Oracle and so on. This way the information is searchable and it will be easy to write programs to import the data into existing systems.

EDI is increasingly adopted in the health care industry and mandated by the HIPAA act of 1996. EDI is ideal to exchange information between computers but it is inherently hard to read for humans. Many complex properties are represented as two-letter abbreviations.

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The beginning of an 835 EDI file

The above is an example of an 835 file. One can easily see bits of information but a lot of it is translated into codes that are not intelligible. Most often EDI files have no carriage returns so that the information looks even more confusing.

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The display of the Remittance advice for a single claim

Here you can see that the information resembles the paper EOB's or EOP's that were traditionally sent by mail. 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.

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. Read more in Identifying the Information.