Providers who transmit information electronically must use standard medical codes, and eliminate the use of duplicative and local codes. Health plans, which use a wide variety of codes and formats to transact business with providers and clients, must be able to accept and respond to the standard electronic data interchange (EDI) transaction formats and related medical and non-medical code sets. Show
HIPAA Codes837 Health Care ClaimsFor professional, institutional, and dental providers, the 837 provides the capacity to submit electronic health care encounters and claims. Compliance with this electronic transaction includes the use of HIPAA defined, compliant code sets. 835 Health Care Claim Payment/Remit AdviceUtilized by a payer to send electronic remittance advice (ERA) or electronic explanation of payment (EOP) to a requesting provider. Also includes payment of health care claims. However, Cigna has elected to implement only the ERA portion of this transaction and will continue to utilize existing banking and related Electronic Fund Transfer processes for payment of health care claims. Providers must request an 835 through their Clearinghouse; it is not automatic. 270/271 Inquiry/Response for EligibilityAllows determination of subscriber or dependent eligibility as well as the benefit information for the subscriber or dependent. The 270 is the inbound eligibility/benefit inquiry transaction from a provider to a health plan. The 271 is the eligibility/benefit response transaction of this set. This is an interactive transaction set and responses are "real time." 276/277 Inquiry/Response for Claim StatusUsed by providers to request status on a submitted claim (276) and to receive a status response (277). The 276 is utilized by institutional, professional and dental providers, and supplemental health care claims processors as defined by the regulations. The 277 response transactions are utilized by payers and other entities that process claims. This is an interactive transaction set and responses are "real time." 278 Referral Certification, Authorization, Extensions and AppealsReferral Certification: Used by providers to request certification for a patient to receive health care services. Also provides capacity to appeal a UM decision. Authorization: Provider receives permission from review entity/UM to refer the patient to a specialist, admit the patient to a facility, or administer medical services or treatment to the patient. This transaction also covers pre-certification prior to elective hospitalization or treatment, as required, for determination of medical necessity. This transaction allows the provider to request an extension to a previously approved authorization, pre-certification, or referral. The 278 is implemented as an interactive transaction. 131 International Classification of Diseases Clinical Mod (ICD-9-CM) ProcedureThe International Classification of Diseases, 9th Revision, Clinical Modification, describes the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations. 132 National Uniform Billing Committee (NUBC) CodesRevenue codes are a classification of hospital charges in a standard grouping that is controlled by the National Uniform Billing Committee. Place of service codes specify the type of location where a service is provided. 134 National Drug CodeThe National Drug Code is a coding convention established by the Food and Drug Administration to identify the labeler, product number, and package sizes of FDA-approved prescription drugs. There are over 170,000 National Drug Codes on file. 135 American Dental Association CodesThe CDT contains the American Dental Association's codes for dental procedures and nomenclature and is the nationally accepted set of numeric codes and descriptive terms for reporting dental treatments. 139 Claim Adjustment Reason CodeBulletins describe standard codes and messages that detail the reason why an adjustment was made to a health care claim payment by the payer. 229 Diagnosis Related Group Number (DRG)A patient classification scheme that clusters patients into categories on the basis of patient's illness, diseases, and medical problems. 235 Claim Frequency Type CodeA variety of codes explaining the frequency of the bill submission. 240 National Drug Code by FormatPublication includes manufacturing and labeling information as well as drug packaging sizes. 245 National Association of Insurance Commissioners (NAIC) CodeCodes that uniquely identify each insurance company. 307 National Association of Boards of Pharmacy NumberA unique number assigned in the U.S. and its territories to individual clinic, hospital, chain, and independent pharmacy locations that conduct business at retail by billing third-party drug benefit payers. The National Council for Prescription Drug Programs (NCPDP) maintains this database under contract from the National Association of Boards of Pharmacy. The National Association of Boards of Pharmacy is a seven-digit numeric number with the following format SSNNNNC, where SS=NCPDP assigned state code number, NNNN=NCPDP assigned pharmacy location number, and C=check digit calculated by algorithm from previous six digits. 411 Remittance Remark CodesThese codes represent non-financial information critical to understanding the adjudication of a health insurance claim. 513 Home Infusion EDI Coalition (HIEC) Product/Service Code ListThis list contains codes identifying home infusion therapy products/services. 530 National Council for Prescription Drug Programs Reject/Payment CodesA listing of NCPDPs payment and reject reason codes, the explanation of the code, and the field number in error (if rejected). 537 Health Care Financing Administration National Provider IdentifierThe Health Care Financing Administration is developing the Plan ID, which will be proposed as the standard unique identifier for each health plan under the Health Insurance Portability and Accountability Act of 1996. What is performed by a payer to determine the appropriateness of medical services?Prior authorization (also called pre-authorization or "pre-auth") is a common payer process that requires providers to submit medical necessity documentation in a specific way for a requested therapy or service before coverage is approved.
What type of information is found on a remittance advice?WHAT IS AN RA? The Remittance Advice (RA) contains information about your claim payments that Medicare Administrative Contractors (MACs) send, along with the payments, to providers, physicians, and suppliers.
What is a remittance code?Remittance Advice Remark Codes (RARCs) may be used by plans and issuers to communicate information about claims to providers and facilities, subject to state law. The following RARCs related to the No Surprises Act have been approved by the RARC Committee and are effective as of March 1, 2022.
What happens if a provider does not provide an itemized statement?A claim was denied because it was not filed in a timely manner. Itemized statements if asked must be supplied: by the provider within 30 days or they could be fined $100 per outstanding request.
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Which of these HIPAA transactions is sent by a payer to answer a question about a submitted claim?
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