1 Early Intervention Central Billing Office Electronic Claims Submission

2 Early Intervention Central Billing Office Electronic claims Health Insurance Portability and Accountability Act (HIPAA) How providers can generate HIPAA-compliant Electronic Claims Benefits of electronic claims submission Requirements for submitting electronic claims Factors and considerations Resources AGENDA

3 Early Intervention Central Billing Office Electronic claims Electronic Data Interchange (EDI) applications, including electronic claims have been used for many years. Electronic claims are an alternative to paper claims Generated by computer systems Transmitted electronically to payers by computer systems Until recently (HIPAA), no universal standard has existed

4 Early Intervention Central Billing Office HIPAA Among other things, the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA): Set standard formats for electronic transactions States that if a provider desires to conduct a “standard transaction” (an electronic transaction in the HIPAA standard format) a payer may not refuse

5 Early Intervention Central Billing Office Electronic Claims Pre-HIPAA electronic file layouts: System “A”FieldSystem “B” Patient First Name15 characters1Date of ServiceDD/MM/YY Patient Last Name25 characters2Transaction code3 numbers Account Number40 characters or numbers 3CPT Code9 characters CPT Code9 numbers4Diagnosis Code6 characters Diagnosis Code6 numbers including decimal 5Account Number35 numbers Transaction code4 characters6Patient First Name12 characters Date of ServiceYYY/MM/DD7Patient Last Name23 characters

6 Early Intervention Central Billing Office Electronic Claims Simplification of translation or mapping:

7 Early Intervention Central Billing Office HIPAA Impact on the EI-CBO T he EI-CBO u pgraded its claims processing system by purchasing a translator that allows the EI-CBO to send and receive electronic transactions in HIPAA-compliant format. Part of this upgrade, called Rapid Data Entry, has allowed us to significantly reduce turn-around time on paper claims.

8 Early Intervention Central Billing Office HIPAA Impact on Providers Option 1: Providers can continue to submit claims to the EI-CBO on paper. No changes are required.

9 Early Intervention Central Billing Office HIPAA Impact on Providers Option 2: Providers may submit electronic claims to the EI-CBO. This option will require an investment of time and resources. It is important for you to consider the requirements and costs to submit claims electronically. The requirements will differ based on which electronic option you elect to pursue.

10 Early Intervention Central Billing Office Generating HIPAA compliant electronic claims Use billing or practice management software to: Submit claims directly to the EI CBO using billing or practice management software that is able to produce claims in HIPAA compliant format. OR Submit claims to a clearinghouse using billing or practice management software that is able to convert claims into HIPAA compliant format

11 Early Intervention Central Billing Office Submit claims directly to the EI CBO

12 Early Intervention Central Billing Office Submit claims to a clearinghouse

13 Early Intervention Central Billing Office Clearinghouses Under HIPAA, a clearinghouse is an entity that does either of the following functions: Translates data that is not HIPAA-compliant into HIPAA- compliant format. Translates data that is HIPAA-compliant into a non-compliant format. Clearinghouses also facilitate the transmission of electronic transactions between payers and providers. Electronic Claims

14 Early Intervention Central Billing Office Electronic claims Some Clearinghouses: THIN Envoy/WebMD McKesson The EI-CBO has contracted with THIN.

15 Early Intervention Central Billing Office Requirements For Each Option RequirementsDirectUsing THIN Modem or internet accessYes ComputerYes Billing/Practice Management Software Able to send electronic transactions Able to create HIPAA compliant transactions Yes No Technical and/or software expertise able to assist with configuration and installation of software Yes If insurance is to be billed, claims must be mailed with EOB attached. Yes

16 Early Intervention Central Billing Office How to determine if you should make this investment to send claims electronically? Evaluate your current resources, and what you will need to purchase to be able to send claims electronically Calculate your current operational costs to determine the financial feasibility of automating your business. Will decrease your total operational costs if invest in the ability to send electronic claims?

17 Early Intervention Central Billing Office Generating HIPAA compliant electronic claims Evaluate your current resources Will you need to purchase computer equipment? Will you need to purchase internet access?

18 Early Intervention Central Billing Office Generating HIPAA compliant electronic claims Evaluate your current resources Will you need to purchase billing or practice management software capable of submitting electronic claims? Billing/practice management software packages can range in price from under $2,000 to in excess of $100,000, depending on the features and capabilities.

19 Early Intervention Central Billing Office Generating HIPAA compliant electronic claims Evaluate your current resources If you currently utilize a billing or practice management system will you need to purchase additional software to be able to send HIPAA compliant transactions? Will you need to hire a consultant or do you have a person on staff with a high level of technical expertise? Consulting fees can run from $75 to $200 per hour.

20 Early Intervention Central Billing Office How electronic claims submission can benefit you: decrease postage and paper costs track each claim through a submission report (see for examples of THIN reports) increase productivity within your organization Claims are checked for completeness - you will know immediately if a claim has been rejected for mistakes on the claim

21 Early Intervention Central Billing Office Available resources: A listing of Practice Management software vendors can be found on the internet. The web addresses for several sites are listed below. The information found in each directory is for informational purposes and is being provided to assist you with your research. The Health Information Network (THIN) Professional Vendor List. This Professional Vendor List represents a number of available sources for the electronic services. It is in no way an endorsement or recommendation of any single Vendor. The address is: HIPAA.ORG EDI Practice Management System Directory:

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