Chapter 8 Electronic Data Interchange: Transactions and Security Electronic Data Interchange: Transactions and Security Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2 Learning Objectives  Summarize advantages of electronic claim submission.  Identify the transactions and code sets to use for insurance claims transmission.  State which insurance claim data elements are required or situational for the 837P standard transaction format.  Describe necessary components when adopting a practice management system.  Describe the use of patient encounter forms and scannable encounter forms in electronic claim submission.  Name some methods of interactive computer transactions for transmitting insurance claims.

3Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Learning Objectives (cont’d.)  List computer transmission problems that can occur.  Explain the difference between carrier-direct and clearinghouse electronically transmitted insurance claims.  State measures used to secure privacy of electronic mail, Internet, and instant messaging.  List HIPAA administrative safeguards for electronic protected health information.  Explain the handling of data storage and data disposal for good electronic records management.

4Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Chapter 8 Lesson 8.1

5Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Electronic Data Interchange (EDI)  Used for transmission of health insurance claims  Transmitted data is encrypted  Improves efficiency of claims submissions

6Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Advantages of Electronic Claim Submission  No signatures or stamps  No searching for an insurance carrier’s address  No postage costs or trips to post office  No need to store or file claim forms  Electronic claims leave an audit trail  Improved cash flow  Quicker processing time and payment  Reduced overhead and labor costs

7Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Clearinghouses  Claims are checked electronically  Claims with missing/incorrect information are rejected  Rejected claims are sent back to the provider with a report  Batches of acceptable claims are sent to the appropriate payer  Corrected claims are reprocessed

8Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Advantages of a Clearinghouse  Translation of various formats to the HIPAA- compliant standard format  Reduction in time of claims preparation  Cost-effective method through loss prevention  Fewer claims rejections  Fewer delays in processing and quicker response time  More accurate coding with claims edits  Consistent reimbursement

9Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. HIPAA Transaction and Code Set (TCS) Benefits  More reliable and timely processing  Improved data accuracy  Easier and more efficient information access  Better tracking of transactions  Reduction of data entry/manual labor  Reduction of office expenses

10Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. HIPAA Required Code and Data Sets  ICD-9-CM codes  CPT-4 codes  CDT codes  NDC codes  ICD-10-CM/ICD-10-PCS codes  Taxonomy codes  Patient account number  Relationship to patient  Facility code value  Patient signature source code

11Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Electronic Formats  Specialist authorization  Reimbursement claims  Request and respond to additional information  Healthcare claims/attachments/claims status  Coordination of benefits  Healthcare payment and remittance advice  Plan enrollment/disenrollment/eligibility  Premium payments  Referrals  First report of injury

12Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Standard Unique Identifiers  Standard unique employer identifier  Standard unique healthcare provider identifier  Standard unique health plan identifier  Standard unique patient identifier

13Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Practice Management System  Should be able to prepare, send, receive, and process HIPAA standard electronic transactions  Can help track receipt of Notice of Privacy Practices (NPP), patient treatment consents or authorization, and mapping disclosures

14Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. HIPAA-Ready PMS  Set security access to patient files in the software  Indicate date of receipt and signing of NPP  Insert date of patient’s authorization  Maintain files of practice’s authorization and notification forms  Track requests for amendments, restrictions on disclosure of PHI, and physician response to request  Track expiration dates

15Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Encounter or Multipurpose Billing Forms  Also called charge slip, multipurpose billing form, patient service slip, routing form, superbill, transaction slip  Customized to meet the needs of the healthcare office  May include preprinted procedural or diagnostic codes  Scannable encounter forms save time

16Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Do’s and Dont’s for Keying Insurance Data for Claims Submission DO: Use the patient account numbers to differentiate between patients with similar names. DO: Use correct numeric locations of service codes, current, valid CPT or HCPCS procedures codes. DO: Print an insurance billing worksheet or perform a front-end edit to look for and correct all errors before the claim is transmitted to the third-party payer. DO: Request electronic-error reports from the third-party payer to make corrections to the system. DO: Obtain and cross-check the electronic status report against all claims transmitted. DON’T: Use special characters. DON’T: Bill codes using modifiers -21 or -22 electronically unless the carrier receives documents to justify more payment.

17Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Encoder  Signature requirements  Physician  Patient

18Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Clean Electronic Claims Submission  Claim scrubber software  Encoder software  Electronic clearinghouse  Single and batch claims review

19Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Chapter 8 Lesson 8.2

20Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Interactive Transactions  Back-and-forth communication between two computer systems  Real time communication allows instant information transfer  Electronic funds transfer (EFT) can speed up reimbursement

21Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Electronic Remittance Advice (ERA)  ERA: Online transaction about the status of a claim  Medicare ERA  formerly called Medicare explanation of benefits (EOMB or EOB)  based on American National Standards Institute (ANSI) Accredited Standards Committee X12 (ASC X12) Health Care Claim Payment/Advice (835) or ANSI 835

22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Procedures for Claim Transmission  Set up the database.  Enter data.  Batch or compile a group of claims.  Connect the computerized database with the clearinghouse or direct to the payer.  Transmit the claims.  Review the clearinghouse reports.

23Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Methods for Sending Claims  Cable modem  Digital subscriber line (DSL)  T-1  Direct data entry (DDE)  Application service provider (ASP)

24Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Computer Claims Systems  Carrier-direct  The medical practice has its own computer and software to process claims.  The insurer sometimes leases a dedicated terminal to the physician.  Clearinghouse  The physician’s office sends paper claims or a disk or tape to the clearinghouse, which forwards a batch of claims to the insurer.

25Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Transmission Reports  Send and receive file reports  Scrubber report  Transaction transmission summary  Rejection analysis report  Electronic inquiry or claims status review

26Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Administrative Simplification Enforcement Tool (ASET)  Online tool  Assists healthcare providers, payers, clearinghouses, and others to submit complaints regarding the HIPAA TCS rule

27Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. The Security Rule: Administrative, Physical, and Technical Safeguards  Administrative safeguards  information access controls  internal audits  risk analysis and management  termination procedures  Technical safeguards  access controls  audit controls  automatic log-offs  use of passwords

28Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. The Security Rule (cont’d.)  Physical safeguards  media and equipment controls  physical access controls  secure workstation

29Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Computer Security Prevention Measures  Use software that stores files in coded form  Never leave disks or tapes unguarded  Use a privacy filter on the computer monitor  Log off computer before leaving work station  Double-check credentials of all consultants  Read equipment manuals, especially “Security Controls” information, and follow all directions  Store confidential data on diskettes or “zip” disks, not the hard drive  Store all diskettes in a locked, secure location  Use firewall and antivirus software  Develop passwords for all computer users  Use only account numbers in

30Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Records Management  Data storage: back up data frequently  Electronic power protection: surge suppressors or uninterruptible power supply (UPS)

31Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Selection of an Office Computer System  Cost of basic equipment—purchase or lease?  Accessories  Space requirements  Electrical/transmission lines  Separate fax and modem lines?  Costs of electricity  Telephone lines  Maintenance  Software