The 837, or more specifically the ANSI X12 837 004010X098A1 (no, we didn’t make that up), is the format for electronic claims. This is the only format that insurance carriers will accept when receiving electronic claims.
This format was required in October of 2003. Most people get around having to deal with 837’s by sending their claims to a clearinghouse via an HCFA/CMS-1500 print image file. The clearinghouse then converts the HCFA/CMS-1500 image into an 837 and forwards it to the carrier. This is a wonderful solution if the clearinghouse is up to the task and stays on top of the changing requirements for 837’s as it relates to Therapy. Creating 837’s from the Clinic Controller provides the luxury of knowing that the 837 is formatted with all available therapy billing knowledge and that it is going to be our priority to continue to update the 837 generations as carriers change their requirements for a therapy claim.
The 837 provides many different places to put information. Imagine an HCFA/CMS-1500 with several thousand boxes on it, and you will be close to picturing n 837. Luckily, we do not have to deal with most of them, and most of the information required is already available and is the information we are used to providing for the HCFA/CMS-1500. The next few sections will detail the new fields. Many of these fields are NOT required, but you may have to fill them in for certain carriers.
Additional Case Information
There are two fields in the case dialog (found in the Auxiliary Information section, see appendix for more information) that may be populated and will be reported on the 837. These are:
837 Case Information
|Country of Accident||Used when reporting auto accidents that happen outside the United States.|
|Special Program Code||Used when required by the insurance carrier.|
Additional Carrier/Policy Information
The seven fields that are available for the Policies dialog may have their defaults set in the carrier dialog. This allows default values to be set at the carrier level, and then when a policy is created with that carrier, the policy will be created with the values set at the higher level.
The seven fields that are available are as follows:
837 Carrier/Policy Information
|Primary Claim Filing Indicator (CFI)||Required on the primary claim for all carriers involved. (When billing the initial claim, the primary CFI will be used for all carriers that appear on the claim.)|
|Primary Insurance Type Code (ITC)||Required on the primary claim for all carriers involved. (When billing the|
|Secondary Claim Filling Indicator (CFI)||Required on all other claim levels (secondary, tertiary, etc.) for all carriers involved. (When billing any claim other than the initial/primary claim, the secondary CFI will be used for all carriers that appear on the claim.)|
|Secondary Insurance Type Code (ITC)||Required on all other claim levels (secondary, tertiary, etc.) for all carriers involved. (When billing any claim other than the initial/primary claim, the secondary ITC will be used for all carriers that appear on the claim.)|
|100B NM109||Only used when filling 837s to carriers that do not follow the 837 specifications for this element. Enter a value to force that value onto the 837.|
|2000A PRV||Only used for special placement of the taxonomy code when specifically requested by the carrier.|
|2310B PRV Omit||Used in conjunction with 2000A PRV. This can be set to True to prevent the taxonomy code from repeating in 2310B PRV.|
|UPIN Handling||Allows you to specify whether or not the doctor's UPIN should be included on the 837 and in which loop/segment it should appear.|
Additional Visit Information
Additional information may be required at the visit level. This is only going to be required in rare circumstances. These two fields are:
837 Carrier/Policy Information
|Claim Submission Reason||Used when required by the carrier.|
|Delay Reason Code||Used when required by the carrier.|
Additional Doctor Information
With the HCFA, it was only possible to put a single identifier for the doctor, which was the UPIN. Under the 837, there is space for many different additional identifiers. Many of these will not be required, and with the advent of the NPI, many of them should never be required.
Another item of note, the 837 supports the identification of two different doctors, the Referring Doctor, and the Supervising doctor. These may be different or the same and are set in the Case under General Information.
837 Doctor Information
|NPI||Used when required by the carrier.|
|0B||State License Number|
|1B||Clue Shield Number|
|1C||Medicare Provider Number|
|1D||Medicaid Provider Number|
|EI||Employers ID Number|
|N5||Provider Plan Network Number|
|Specialty Code||Specify a doctor's specialty|
|SY||Social Security Number|
Additional Provider Information
As with the Doctor, the 837 has the ability to require more rending provider information. Whereas the HCFA simply required a Therapist Signature field, the 837 wants the therapist’s name broken down into First, Last, Middle and Suffix.
837 Rendering Provider Information
|IsPerson||Required - is the rendering provider a person or entity|
|First Name||Required - Providers first name.|
|Last Name||Required - Providers last name.|
|Middle||Required - Providers middle initial.|
|Suffix||Required - Providers name suffix (ie. Jr., Sr.)|
|Taxonomy Code||Required - Taxonomy Code for the provider (see below)|
|NPI||Use if required by the carrier.|
Clearing House vs Carrier Direct
Which is better, using a clearinghouse or going direct? This is a debatable topic, and each has its pros and cons. It all depends on how much manpower you are willing to put forward to bill direct to make it work for you.
Advantages of Carrier Direct
|Cost||There is no direct cost associated with sending a claim directly to an insurance carrier.|
|Immediate Knowledge||There is no middle man, acceptance or rejection should be known immediately.|
Disadvantages of Carrier Direct
|Individual Relationships||You will have to establish an EDI relationship with each carrier you wish to send directly to.|
|Separate Claim Files||You will need to create claim files for each carrier and then log into each carrier individually to send your claims.|
|Separate Claim Status||Claim status will have to be checked individually with each carrier.|
|More Knowledge Required||User must stay on top of changes in billing and know how it affects them and sending claims.|
Advantages of Clearing Houses
|Single Relationship||One place where all claims are sent and processed. No need for individual EDI agreements with each carrier.|
|Single Claim File||One file to send all electronic claims.|
|Single Claim Status||Single point of contact for receiving.|
|Knowledge||Clearing house should have a good relationship with the carriers they send claims to and will have a better conduit of communication with them.|
Disadvantages of Clearing Houses
|Single Relationship||This advantage cuts two ways. If the clearing house is having problems then all your claims are having problems.|
|Cost||There is a direct cost associated with every claim that is sent.|