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Claims & Billing Definitions

Claims & Billing Definitions

837 File

Basically, it’s an electronic file that contains information about a patient claims. This form is submitted to a clearinghouse or insurance company instead of a paper claim. The EDI 837 transaction set is the format established to meet HIPAA requirements for the electronic submission of healthcare claim information

Batch 837

This is a file format for Professional (HCFA 1500) format claims and encounters.

835

The Electronic Remittance Advice (ERA), or 835, is the electronic transaction that provides claim payment information. These files are used by practices, facilities and billing companies to auto-post claim payments into their systems.

Upload 835

Uploading of electronic 835 remittance files into the EVV system is a mandatory requirement for all Case Management and Home Care Providers.

Reconcile 835/EOB

This is basically for discrepancies with payor and re-submission of 835. Following submitting the bill electronically if your payor has rejected the claims for full amount you can reconcile the bill for discrepancy and submit again.

EDI File

EDI stands for the electronic data interchange and is also known as 837 file. The 837 or EDI file is a HIPAA form used by healthcare suppliers and professionals to transmit healthcare claims.

Eligibility 270/271

EDI 270 health care eligibility/benefit inquiry transaction set is used to request information from a healthcare insurance plan about a policy’s coverages, typically in relation to a particular plan subscriber.

The 270 document typically includes the following

Details of the sender of the inquiry (name and contact information of the information receiver)

Name of the recipient of the inquiry (the information source)

Details of the plan subscriber about to the inquiry is referring

Description of eligibility or benefit information requested

The 270 transaction is used in conjunction with the EDI 271 transaction. The 271 is the Health Care Eligibility/Benefit Response and is used to transmit the information requested in a 270.

Use of both 270 and 271 transactions allows healthcare service providers to create HIPAA-compliant files requesting eligibility details for a patient.