Skip to Content

Provider Manual

Electronic claims

Last Updated on August 28, 2018

Introduction

This section of information outlines transmission media available, telecommunication specifications, testing procedures and output report feedback for electronic claims.

The Health Insurance Portability & Accountability Act (HIPAA)

HIPAA is a federal mandate passed by congress in 1996, which addresses the high administrative costs of health care. SHP is fully compliant as of October 16, 2003.

The Centers for Medicare & Medicaid Services (CMS) has been delegated authority over HIPAA Administrative Simplification provisions including Transaction & Code Set Standards. Medicare no longer accepts paper claims, with few exceptions.

HIPAA Administrative Simplification has been adopted to enable health information to be exchanged electronically, an electronic data interchange (EDI) standard, with the goals of improving the operation of the health system and reducing administrative costs.

Covered entities include health plans, clearing houses and providers. HIPAA Administrative Simplification does not mandate changes to paper transactions.

  • Health plans can include, but are not limited to, Managed Care Organizations, HMOs, TPAs, ERISA plans, commercial payers, government health plans, State Medicaid agencies, and Medicare plans Part A and Part B.
  • Healthcare clearinghouses may accept non-standard transactions for the purpose of translating them into standard transactions and translating standard transactions into non-standard transactions for customers.
  • Providers are defined as a provider of medical or other health services and any other person furnishing health care services or supplies including, but not limited to, physicians, dentists, nursing homes, and hospitals.

An electronic transaction is the exchange of electronic information between two parties to carry out administrative or financial activities within the health care system.

The electronic transactions include the following types of information exchanges:

  • Institutional Health Care Claim – 837
  • Professional Health Care Claim – 837
  • Dental/ADA Claim – 837
  • Health Care Remittance Advice – 835
  • Eligibility for a Health Plan Request and Response – 270/271
  • Health Care Claim Status Request and Notification – 276/277
  • Referral Authorization 278 – Health Care Services Review

Code sets are a standard method of identifying, classifying and describing something such as conceptual or physical attributes of persons, places or things. Code sets are used to identify providers, employers, health plans, and beneficiaries or enrollees; diagnoses, medical procedures, pharmaceuticals; and other characteristics of patients, providers or services. Generally a code set consists of numerical or alphanumeric codes and an associated description. Code sets define the valid data that can be used within a transaction.

Included in the HIPAA compliant transactions are the following Medical Data Code Sets:

  • ICD-9, Volumes 1 and 2, as maintained and distributed by HHS
  • The combination of Health Care Financing Administration Common Procedure Coding System (HCPCS), as maintained and distributed by HHS, and Current Procedural Terminology, Fourth Edition (CPT-4), as maintained and distributed by the American Medical Association, for physician services and other health care services
  • National Drug Codes (NDC), as maintained and distributed by HHS for drugs and biologics
  • Code on Dental Procedures and Nomenclature, as maintained and distributed by the American Dental Association for dental procedures

Wisconsin SHFS HIPAA-related publications, a list of HIPAA acronyms, and other valuable HIPAA information can be found at http://www.dhfs.state.wi.us/hipaa/

A provider may choose to submit claims to clearinghouses or may choose to submit electronic claims directly to SHP. Claim files will be accepted in 4010 format.

The intent is to make the conversion from paper claims to electronic claims submission as easy as possible. If any procedures or requirements of the system as outlined in this section are not acceptable, please contact Security Health Plan to try to develop an alternative.