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Electronic Data Interchange (EDI)

Electronic Submission of Claims (HIPAA 837)
HIPAA claims requirements (5010)
Benefits of Using EDI for Claim Submissions
Electronic Submission of Claims Types
Electronic Submission of Claims Types

Electronic Data Interchange (EDI) is an electronic exchange of information in a standardized format that adheres to all Health Insurance Portability and Accountability Act (HIPAA) requirements. It is the transfer of structured data, by agreed message standards, from one computer system to another without human intervention. The EDI transactions listed below are currently supported by Kaiser Permanente.

Electronic Submission of Claims (HIPAA 837)

Kaiser Permanente currently supports electronic submission of claims. Claims can be submitted to Kaiser Permanente through direct claim submissions or, if necessary, through a Kaiser Permanente affiliated clearinghouse.

Please contact Provider Relations Monday through Friday 9:00 a.m. PT to 5:00 p.m. PT.

    Durable Medical Equipment/Prosthetics and Orthotics
       818-557-6126 and 510-268-5473
      
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HIPAA claims requirements (5010)

The federal government mandated that all covered entities (including providers, clearinghouses and health plans) must transition to the latest version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards and code sets. This affects both electronic and paper claims.

The Centers for Medicare and Medicaid Services (CMS) mandates that all payers, physicians and hospitals exchange key business transactional data by January 1, 2012, using a new HIPAA 5010 format for electronic data interchange (EDI) transactions.

Along with other payers, Kaiser is undertaking preparations to implement these latest standards.

    Requires update to version 5010 for HIPAA transactions
      - 4010a1 has been around since 2002
      – No new HIPAA transactions added at this time
      – Some payers voluntarily adding new acknowledgements
    Internal development and testing / demonstration of
    Ability to send and receive 5010 required by 12/31/2010
    External Trading Partner testing / Full Compliance required by 12/31/2011
    Effective 1/1/2012 only 5010 transactions will be allowed

For more information on HIPAA 5010 refer to this site*.

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Benefits of Using EDI for Claim Submissions

    Reduced Overhead Expenses: Administrative overhead expenses are reduced, because the need for handling paper claims is eliminated.

    Improved Data Accuracy: Because the claims data submitted by the provider is loaded directly into Kaiser Permanente’s computer by the clearinghouse, data accuracy is improved.

    Cleaner Claim Submissions: "Up-front" edits applied to the claims data while information is being entered at the provider’s office, and additional payer-specific edits applied to the data by the clearinghouse before the data is transmitted to the appropriate payer for processing.

    Reduced Turnaround Time: EDI claims bypass manual processes and paper handling at Kaiser Permanente; therefore, the turnaround time for processing EDI claims is substantially reduced (as compared to processing paper claims).

    Bypass US Mail Delivery: Providers save time by bypassing the U.S. mail delivery system.

    Reduced Payer-Specific "Exceptions": Industry-accepted standardized medical claim formats will tend to reduce the number of exceptions currently required by multiple payers.
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Electronic Submission of Claims Types

Use these forms for Submit electronic claims transactions using the following claims types:

    837P Claim/Encounter: For professional services and supplier

    837I Claim/Encounter: For facilities and hospitals
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Electronic Submission of Claims Types

To receive an electronic provider Explanation of Payment (EOP), providers should already be set up for electronic submission of claims.

Please contact Provider Relations at Monday through Friday 9:00 a.m. PT to 5:00 p.m. PT.

    Durable Medical Equipment/Prosthetics and Orthotics
       818-557-6126 and 510-268-5473

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