Unlocking Efficiency: Using EDI 276 to Simplify Dental Surgery Claim Processing

In today's fast-paced healthcare environment, effective claims processing is critical for hospitals to secure timely payments and financial stability. In this blog article, we'll look at a frequent scenario in which a hospital has to check on the status of a claim for a patient who had dental surgery. To simplify this procedure, we'll look at using Electronic Data Interchange (EDI) standard 276.

Background

The processing of healthcare claims entails a complicated network of information exchange between providers, payers, and patients. Timely claim processing is crucial to ensuring providers get compensated for their services. To ease the electronic transfer of healthcare data, standards such as EDI have been created.

Conceptualizing a Solution with EDI 276 :

EDI 276: The Data Transmission Standard

The Electronic Data Interchange (EDI) 276 standard was created exclusively for healthcare claim status enquiries. It enables healthcare providers to electronically verify the status of their claims. This standard simplifies communication between hospitals and payers, minimizing human work and the possibility of mistakes.

Highlighting the Sections -

In our case, we'll concentrate on key components of the EDI 276 transaction:

1. Claim Status Request (276): This is the core transaction. It contains all the necessary information to inquire about the status of a claim.
2. Patient Information: Identifies the patient whose claim status is being requested.
3. Provider Information: Specifies the hospital or healthcare provider.
4. Payer Information: Identifies the insurance company or payer.
5. Claim Information: Contains details about the claim, including claim ID and claim type.
6. Service Information: Specifies the service provided (dental surgery in this case).
7. Date of Service: Indicates the date when the service was provided.
8. Price Information: Contains pricing details for the service.
9. Net Amount: Represents the total amount due for the service.
10. Terminology Standards: The transaction may refer to terminology standards like SNOMED CT or LOINC for coding medical terms consistently.

Sample EDI 276 Data -

ISA*01*0000000000*01*0000000000*ZZ*ABCDEFGHIJKLMNO*ZZ*123456789012345*101127*1719*U*00400*000003438*0*P*>

GS*HR*00000003B* RECEIVER 201309240536*1972017*X*005010X212

ST*276*1973007*005010X212

BHT*0010*13*406ba0b7-700d-4c99-8c75-6da5adaf1da4*20130924*0536

HL*1**20*1

NM1*PR*2*TEST*****PI* RECEIVER

HL*2*1*21*1

NM1*41*1*A GOOD HOSPITAL*****46*1234567890

HL*3*2*19*1

NM1*1P*1*THE HOSPITAL*****XX*9876543210

HL*4*3*22*0

DMG*D8*19980510*F

NM1*IL*1*DOE*JANE****MI*12345678901

TRN*1*406ba0b7-700d-4c99-8c75-6da5adaf1da4

REF*EJ*61157208-000

AMT*T3*1090.00

DTP*472*RD8*20130819-20130819

SE*16*1234

GE*1*1421

IEA*1*000006768

Sample FHIR Data –

<?xml version="1.0" encoding="UTF-8"?>

<Claim xmlns="https://hl7.org/fhir">

? <id value="100150"/>

? <text>

??? <status value="generated"/>

??? <div xmlns="https://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div>

? </text>

? <identifier>

??? <system value="https://happyvalley.com/claim"/>

??? <value value="12345"/>

? </identifier>

? <status value="active"/>

? <type>

??? <coding>

????? <system value="https://terminology.hl7.org/CodeSystem/claim-type"/>

????? <code value="oral"/>

??? </coding>??

? </type>

? <use value="claim"/>

? <patient>

??? <reference value="Patient/1"/>

? </patient>

? <created value="2014-08-16"/>

? <insurer>

??? <reference value="Organization/2"/>

? </insurer>

? <provider>

??? <reference value="Organization/1"/>

? </provider>

? <priority>

??? <coding>

????? <code value="normal"/>

??? </coding>

? </priority>

? <payee>

??? <type>

????? <coding>

??????? <code value="provider"/>

????? </coding>

??? </type>

? </payee>

? <careTeam>

??? <sequence value="1"/>

??? <provider>

????? <reference value="Practitioner/example"/>

??? </provider>

? </careTeam>

? <diagnosis>

??? <sequence value="1"/>

??? <diagnosisCodeableConcept>

????? <coding>

??????? <code value="123456"/>

????? </coding>?

??? </diagnosisCodeableConcept>

? </diagnosis>

? <insurance>

??? <sequence value="1"/>

??? <focal value="true"/>

??? <identifier>

????? <system value="https://happyvalley.com/claim"/>

????? <value value="12345"/>

??? </identifier>

??? <coverage>

????? <reference value="Coverage/9876B1"/>

??? </coverage>

? </insurance>

? <item>

??? <sequence value="1"/>

??? <careTeamSequence value="1"/>

??? <productOrService>

????? <coding>

??????? <code value="1200"/>

????? </coding>?

??? </productOrService>

??? <servicedDate value="2014-08-16"/>

??? <unitPrice>

????? <value value="135.57"/>

????? <currency value="USD"/>?

??? </unitPrice>?

??? <net>

????? <value value="135.57"/>

????? <currency value="USD"/>?

??? </net>?

? </item>

</Claim>

The provided XML document appears to represent a healthcare claim in the FHIR (Fast Healthcare Interoperability Resources) format. This format is used for sharing healthcare-related information in a structured way. Let's break down the data shared in this XML document :

1. Claim Information:

?? - <id>: A unique identifier for the claim (value="100150").

?? - <text>: Contains human-readable information about the claim.

?? - <identifier>: Contains claim identification information, including the system (value="https://happyvalley.com/claim") and the specific claim value (value="12345").

?? - <status>: Indicates the status of the claim (value="active").

?? - <type>: Specifies the type of the claim, in this case, an "oral" health claim.

1. Claim Usage:

- <use>: Describes the intended use of the claim (value="claim").

1. Patient Information:

- <patient>: References the patient associated with this claim (value="Patient/1").

1. Claim Creation Date:

- <created>: Indicates the date the claim was created (value="2014-08-16").

1. Insurer and Provider Information:

?? - <insurer>: References the insurer organization (value="Organization/2").

?? - <provider>: References the healthcare provider organization (value="Organization/1").

1. Priority Information:

- <priority>: Contains information about the priority of the claim (code value="normal").

1. Payee Information:

- <payee>: Describes the entity that will receive payment for the claim (type "provider").

1. Care Team Information:

- <careTeam>: Specifies the care team involved in the claim, with a sequence number (value="1") and a reference to a practitioner (value="Practitioner/example").

1. Diagnosis Information:

- <diagnosis>: Contains information about the diagnosis associated with the claim, with a sequence number (value="1") and a diagnosis code (code value="123456").

1. Insurance Information:

- <insurance>: Contains insurance-related details, including sequence number (value="1"), focal status (focal="true"), an identifier for the insurance (system="https://happyvalley.com/claim" and value="12345"), and a reference to coverage (value="Coverage/9876B1").

1. Item Information:

- <item>: Describes a specific item or service related to the claim, including sequence number (value="1"), care team sequence (careTeamSequence value="1"), product or service code (code value="1200"), serviced date (value="2014-08-16"), unit price, and net price in USD.

In summary, this XML document shares comprehensive information related to a healthcare claim, including patient, provider, insurer, diagnosis, and service details. It follows the FHIR standard for healthcare data exchange, making it structured and interoperable for healthcare systems and applications to process and understand.

Terminology Standards –

We can see the use of standard terminology codes in the given FHIR code, such as:

1. HL7 Code System: Used to identify the claim type.
2. SNOMED CT: Could be utilized for diagnostic codes.

These standards guarantee that data is understood and interpreted consistently across healthcare systems.

Conclusion -

Finally, utilizing the EDI 276 standard simplifies the process of verifying the status of a dental surgery claim. Hospitals may improve efficiency, decrease manual mistakes, and speed up claim processing by following to established standards and leveraging integration engines. This helps not just healthcare professionals, but it also provides improved patient care through fast compensation. Adopting EDI standards is a critical step toward a more efficient future of healthcare data sharing.