TM provides complete insurance billing. We produce CMS-1500 in paper form and EDI 837 electronic file.
The CMS-1500 is a standard insurance form used by all non-institutional medical providers or suppliers to bill Medicare carriers and durable medical equipment carriers when a provider qualifies for a waiver of electronic submission of insurance. This paper insurance form is also used for billing certain Medicaid state agencies. CMS-1500 is available in various formats including single part, multi-part and continuous feed.
The EDI 837 transaction set is the format established to meet insurance billing requirements for the electronic submission of healthcare insurance information. The insurance information included amounts to the following, for a single care encounter between patient and provider:
- A description of the patient
- The patient’s condition for which treatment was provided
- The services provided
- The cost of the treatment
Glossary of Terms
Unique Identifiers Rule (National Provider Identifier)
HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans, must use only the National Provider Identifier (NPI) to identify covered healthcare providers in standard transactions by May 23, 2007. Small health plans must use only the NPI by May 23, 2008.
Effective from May 2006 (May 2007 for small health plans), all covered entities using electronic communications (e.g., physicians, hospitals, health insurance companies, and so forth) must use a single new NPI. The NPI replaces all other identifiers used by health plans, Medicare, Medicaid, and other government programs. However, the NPI does not replace a provider’s DEA number, state license number, or tax identification number. The NPI is 10 digits (may be alphanumeric), with the last digit being a checksum. The NPI cannot contain any embedded intelligence; in other words, the NPI is simply a number that does not itself have any additional meaning. The NPI is unique and national, never re-used, and except for institutions, a provider usually can have only one. An institution may obtain multiple NPIs for different “subparts” such as a free-standing cancer center or rehab facility
EDI Health Care Claim Transaction Set (837)
EDI Health Care Claim Transaction set (837) is used to submit health care claim billing information, encounter information, or both, except for retail pharmacy claims (see EDI Retail Pharmacy Claim Transaction). It can be sent 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.
Health Level-7 or HL7 refers to a set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers