Electronic Claims Terms
In this list you will find relevant terms related to 837 and 835 EDI (Electronic Data Interchange) transactions through a clearinghouse. Understanding these terms is important in the context of healthcare billing and insurance claims processing. Here's a list to guide you:
835 Transaction: An EDI format used by healthcare insurers to communicate payment and remittance advice.
837 Transaction: A type of EDI format used to submit healthcare claim billing information.
Adjustment: A correction to a claim or payment.
ANSI (American National Standards Institute): An organization that oversees the creation of standards for various industries, including EDI.
Appeal: A request to reconsider a denial or rejection of a claim.
AS2 (Applicability Statement 2): A protocol used to securely and reliably transport EDI data over the Internet.
Batch Processing: Submitting multiple claims together in a single transmission.
Benefit Verification: A process to check the benefits a patient is eligible for under their insurance plan.
Claim: A request for payment of medical services provided.
Claim Status Inquiry: A request to know the status of a submitted claim.
Clearinghouse: An intermediary that receives, processes, and transmits EDI transactions between healthcare providers and payers.
CMS (Centers for Medicare & Medicaid Services): Federal agency overseeing Medicare and Medicaid services.
CMS-1500 Form: A standard claim form used by healthcare providers to bill Medicare and insurance companies.
COB (Coordination of Benefits): A process to determine the order of payment responsibility when a patient has multiple insurance plans.
Credentialing: The process of entering into a contract with a payer to submit claims as an in-network provider. *Sessions Health does not provide credentialing services.
Compliance: Adherence to the rules and regulations governing EDI transactions.
CPT (Current Procedural Terminology): A set of medical codes used to describe medical, surgical, and diagnostic services.
Data Element: A single piece of information in an EDI transaction.
Deductible: The amount a patient must pay for healthcare services before the insurance plan begins to pay.
Denial: A refusal by an insurer to cover a claim.
Direct Data Entry (DDE): Manual entry of EDI data into a system.
EDI (Electronic Data Interchange): Electronic transfer of data in a standardized format between organizations.
EDI Gateway: A point through which EDI transactions pass for validation and transmission.
EFT (Electronic Funds Transfer): Electronic transfer of funds from one bank account to another.
EHR (Electronic Health Record): Digital version of a patient’s medical history.
Eligibility Verification: A process to verify a patient’s insurance coverage.
Encryption: The process of encoding data to prevent unauthorized access.
ERA (Electronic Remittance Advice): An electronic version of a payment explanation.
Explanation of Benefits (EOB): A statement from the insurance company explaining what was covered for a medical service.
HCPCS (Healthcare Common Procedure Coding System): A set of codes used for billing Medicare and Medicaid patients.
HIPAA (Health Insurance Portability and Accountability Act): Legislation providing data privacy and security for medical information.
HL7 (Health Level Seven International): A set of international standards for the exchange of healthcare information.
ICD (International Classification of Diseases): A system for coding diagnoses and procedures.
Implementation Guide: A document detailing how to properly format an EDI transaction.
Loop: A segment of an EDI transaction set that can repeat.
Modifier: A code that alters the description of a service or procedure.
Network Provider: A healthcare provider who is part of a payer's network.
NPI (National Provider Identifier): A unique identification number for healthcare providers.
Out-of-Network: Services provided by a healthcare provider not contracted with the patient's insurance plan.
Payer: An entity (like an insurance company) that pays claims or makes payments.
Prior Authorization: A requirement to obtain approval from a healthcare insurer before providing a service.
Provider: A healthcare entity that delivers medical services.
Real-Time Processing: Immediate processing of a transaction or claim.
Rejection: A response to an EDI transaction indicating that it could not be processed due to errors or discrepancies.
Remittance Advice: A notice of payment sent by a payer to a provider.
Revenue Code: Codes that identify specific accommodation, ancillary, or unique billing considerations.
Segment: A group of related data elements in an EDI transaction.
Trading Partner: An entity engaged in exchanging EDI documents.
Transaction Set: A collection of segments forming a single EDI document.
UB-04 Form: A form used by hospitals to file claims.
X12: A standard for EDI developed by ANSI.
These terms provide a foundational understanding of the complexities involved in 837 and 835 EDI transactions in the healthcare industry.