Medical Claims Clearinghouse Reports

We will first begin by explaining the different reports that medical claims clearinghouses transmit. We earlier learned that Medical Claim Clearinghouses are a bridge between the Practice Management Software and Insurance Carriers. Medical Claim Clearinghouses transmits information from one party to another using the following report options:

270 the Electronic Patient Eligibility (Inquiry)
271 Electronic patient Eligibility (Response)
275 Documentation/Medical Attachment (Example is Texas Workers Compensation)
276 Claim Status Inquiry
277 Claim Status Response

• Claim on File
• Was claim paid
• Reasons claim is Pending payment

278 Prior and Service Authorization
820 Remittance Advice for Managed Care Organizations
834 Medicaid Enrollment for Managed Care Organizations
835 Remittance Advice (electronic files of Explanation of Benefits)
837P Professional Health Claims (CMS-1500)
837I Institutional Health Claims (UB-04)
837D Dental Health Claims
997 Acknowledgement of Claim Status

Getting Data to the Clearinghouse

If your Practice Management (PM) Software Vendor is interfaced with a Medical Claims Clearinghouse then the PM vendor will transmit the claim files and support the EDI reports you receive from the clearinghouse and the health insurance carriers. This is the simplest way of working with a Claim Clearinghouse but not all PM vendors are interfaced.

If your PM vendor is not interfaced with the clearinghouse you will most likely use a PIF file to submit your claims. PIF stands for Print Image File. You enter charges in the Practice Management Software and it creates a PIF file which you download to your desktop and upload it to the clearinghouse. If you were to print the PIF it looks exactly like a CMS-1500 medical claim without the background fields.

ANSI stands for American National Standards Institute. The medical claim is and convert it to text files. An example of a ANSI segment is:

*CHATSWORTH*CA*91311~

This ANSI segment includes the City, State and Zip Code. Groups of Segments are tied together to create a ANSI message. The clearinghouse can convert medical claims into a ANSI message that gets submitted electronically to the health insurance carrier. Other ANSI messages are eligibility, claim status, prior authorization inquiries etc. Because ANSI messages are hard to read clearinghouses convert these into Reports as indicated above.

EDI stands for Electronic Data Interchange. It's a way of transferring data from one computer system to another without requiring a human to touch it. The reports that we talked about above are normally referred to as EDI reports i.e. EDI 837 report.

Other Clearinghouse Articles

Why you need a Claim Clearinghouse

What is a Medical Claim Clearinghouse

Review Medical Claims Clearinghouses