HIPAA

The HIPAA EDI 837 transaction set is the format for e-submission of healthcare claims information. It includes the regulations for collecting a single session encounter occurring between a patient and a healthcare service provider such as:

A brief description of the patient
The patient’s ailment for which treatment was given
A list of services provided to the patient
The cost breakup of the given treatment

As per the latest version of HIPAA 837 Transaction, 5010 the set has been divided into three sections which include:

837P for the professionals
837I for the institutions and
837D for the dental category

The transactions captured in the HIPAA 837 transaction suite are then sent, directly or via clearing houses to the Health Maintenance Organizations (HMO), insurance companies, government agencies like Medicare or preferred providers. Consequently, these payers then send the payments across to the healthcare service providers.

HIPAA EDI 837 Transaction Specification:

As per the Accredited Standards Company, the EDI Specification states the following (Courtesy: http://www.1edisource.com/transaction-sets?TSet=837):

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment.

This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses.

It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements.

The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups.

A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.