CLAIMS OR ENCOUNTERS:

Health care service information (a detailed, itemized record of health care services performed) provided to a health plan for reimbursement. There are four kinds of HIPAA claims or encounters that are detailed in the implementation guides:

􀂾 The ASC X12N 837: Professional Implementation Guide (version 4010X097 & 4010X097A1)

􀂾 The ASC X12N 837: Institutional Implementation Guide (version 4010X091 & 4010X091A1)

􀂾 The ASC X12N 837: Dental Implementation Guide (version 4010X097 & 4010X097A1)

􀂾 The NCPDP: Retail pharmacy transactions (version 5.1 for telecommunications & version 1.1 for batch transactions) Health plans have some flexibility when it comes to which claim implementation guides they will require providers to use.

REMITTANCE ADVICE:

An explanation of claim or encounter processing and/or payment sent by a health plan to a provider.

􀂾 Uses the ASC X12N 835: Health Care Claim Payment/Advice Implementation Guide (version 4010X091 & 4010X091A1) The Health Care Claim Payment /Advice Implementation Guide can be used for both the Remittance Advice and Electronic Fund Transfer Payments to a provider’s bank.

ELIGIBILITY INQUIRY AND RESPONSE:

An inquiry from a provider and the response from a health plan regarding a patient’s eligibility for coverage, or the benefits for which a patient may be eligible.

􀂾 Uses the ASC X12N 270-271: Health Care Eligibility Benefit Inquiry and Response Implementation Guide (version 4010X092 & 4010X092A1)

􀂾 The NCPDP: Retail pharmacy transactions (version 5.1 for telecommunications & version 1.1 for batch transactions)

PRIOR AUTHORIZATION AND REFERRAL:

 An inquiry from a provider and the response from a health plan about a patient’s prior authorization or referral for services.

􀂾 Uses the ASC X12N 278: Health Care Services Review — Request for Review and Response Implementation Guide (version 4010X094 & 4010X094A1)

􀂾 The NCPDP: Retail pharmacy transactions (version 5.1 for telecommunications & version 1.1 for batch transactions)

CLAIMS STATUS INQUIRY AND RESPONSE:

An inquiry from a provider and the response from a health plan about the processing status of a submitted claim or encounter.

􀂾 Uses the ASC X12N 276-277 Health Care Claim Status Request and Response Implementation Guide (version 4010X093 & 4010X093A1)

􀂾 The NCPDP: Retail pharmacy transactions (version 5.1 for telecommunications & version 1.1 for batch transactions)

Source:  www.cms.gov