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Use the 837 claim correctly to comply with HIPAA and positively affect reimbursement

HIM Connection, October 19, 2004

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Whether a provider files claims and receives reimbursement on some form of (discounted) fee-for-service basis or uses encounter forms to substantiate services performed in a managed care situation, the 837 claim is used. Under HIPAA, HMOs that exchange information between the provider and payer sides of the organization must use the 837 claim to do so. Providers who are members of an independent practice association, integrated provider organization, physician-hospital organization, or any other managed care model use the 837 claim for all of their data submission requirements. This streamlines and standardizes data capture and reporting requirements, since the same formats are used regardless of the reimbursement structure.

In addition to requests for payment and pre-paid reporting, the 837 claims allows for submission of data from providers of healthcare services to plan sponsors, employers, regulatory entities, and community health information networks. Providers should be aware that most data reporting requirements come from the UB-92 or CMS 1500 have been accommodated in the 837 claim through negotiation among the interest groups during the standards development process. For example, the Uniform Hospital Discharge Data Set data is incorporated into the 837 institutional claim.

Where federal or state data reporting did not previously draw from a claim (such as the Minimum Data Set [MDS] for long-term care or the Outcomes and Assessment Information Set [OASIS] for home health services), these will continue to require submittal of data via another mechanism (such as through the Home Assessment Validation and Entry software for MDS and OASIS data).

Certain states may find that the 837 claims are not supplying some of the data elements they have collected in the past. Most states are attempting to work this out, but providers may find their state requires separate data reporting. HIPAA does not permit the addition of any data elements to the standard claims, but does not address separate data-reporting requirements not associated with claims.

In association with the state data reporting, providers also need to be aware that state and local codes are not allowed in the 837 claims. Government agencies that have previously used these local codes have been attempting to map them to the national codes. Most states have accomplished this mapping successfully or have appealed for new national codes.

If you have used local codes in the past, it is important to obtain information on how the local codes have been mapped to national codes, so that the corresponding national codes can be used on claims. Update the chargemaster to remove all local codes and replace them with national codes. The local government agency should supply this information in newsletters or bulletins, but providers should be able to request them from the agency directly or through its Web site. Without this map, a provider may select a national code that does not map directly, negatively affecting reimbursement.

This excerpt is adapted from the book HIPAA Transactions Made Simple.

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