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:
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:
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.
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.
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.