Chapter
IV
Transaction Processing
The Enterprise EDI Gateway/Clearinghouse is critical to the process of exchanging electronic
transactions with Trading Partners. Its programs expedite the movement of transactions to their
destination by performing the following functions:
HIPAA Syntax Edits
Control Segment (File) Balancing
Return of 997 Functional Acknowledgments
Routing of Transactions
Although the Enterprise EDI Gateway/Clearinghouse is used for all HIPAA transactions, this
chapter focuses on how it relates to the 837 Health Care Claim transactions. Adjudication
through the Enterprise EDI Gateway/Clearinghouse is a process by which a claim passes
through Level 1 and Level 2 edits to determine proper payment liability. The diagram in this
chapter illustrates the process.
©Anthem
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EDI User Guide
IV-Transaction Processing
Edit Process
Process – 837 Health Care Claim
Enterprise EDI Gateway/
Clearinghouse
Pre-LEVEL 1
2
5
TA1 Report
837
Health Care Claim
Edited
LEVEL 1
3
997
Functional
Acknowledgment
6
LEVEL 2
4
1
835 Electronic
Remittance
864 Text Message
Transaction
(Level 2 Status
Report)
837
Health Care Claim
g
Tradin
r
Partne
Anthem
Trading Partne
Adjudication of a claim includes the following steps:
Submit your 837 Health Care Claims file to the Enterprise
EDI Gateway/Clearinghouse.
The Enterprise EDI Gateway/Clearinghouse returns a
TA1 Report only if an error occurs with enveloping and
duplicate GS control numbers.
The Enterprise EDI Gateway/Clearinghouse returns a 997
Functional Acknowledgment to your mailbox. Any Level 1
errors that occur will be indicated on this report.
NOTE: Contact your EDI Representative if you do not
receive this acknowledgment after you submit your
claims file.
The Enterprise EDI Gateway/Clearinghouse returns an
864 Text Message Transaction (Level 2 Status Report)
to your mailbox. This report will show any Level 2 errors
that occurs.
©Anthem
The Enterprise EDI Gateway/Clearinghouse submits
the edited 837 Health Care Claims file, formatted to
HIPAA standards, to Anthem. (Refer to Chapter VI,
Submitting and Receiving Transactions, for more
information on submitting and receiving.)
After Anthem receives the 837 Health Care Claims
file and is processed, an 835 electronic remittance
is returned to your mailbox via the Enterprise EDI
Gateway/Clearinghouse. (Additional set up is required to
receive an 835 electronic remittance.)
If there are errors, you need to make the necessary
corrections and resubmit your 837 Health Care Claim file
to the Enterprise EDI Gateway/Clearinghouse for claims
processing.
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IV-Transaction Processing
Edit Levels
The Strategic National Implementation Process (SNIP) White Paper on Front End Edits
recommends two levels of reporting:
1)
Level 1: Transaction Format (X12) Syntax Checking
2)
Level 2: HIPAA Implementation Guide Compliance Checking
NOTE: “There are no reporting mechanisms required by the Transactions and Code Sets Final Rule. It is
imperative that an accurate audit trail be maintained to provide relevant feedback between Trading Partners.
Today, the reporting of front-end edits between Trading Partners is inconsistent and incomplete. To solidify
the audit process and add value to the transaction processing cycle, it is critical to include complete, accurate
and consistent reporting mechanisms between trading partners.”
—Front End Edits White Paper, Strategic National Implementation Process (SNIP)
Level 1 Edits
Level 1 edits look for correct syntax according to the X12 Control and Transaction standards
(see below). Errors that occur are reported in the 997 Functional Acknowledgment.
1)
Interchange identification (ISA/IEA)
Correct length of ISA (106 bytes, fixed length)
Legal separators and terminators
Valid Receiver and Sender IDs
2)
Functional Group Identification (GS/GE)
Data content (Control numbers, GE count, group ID, version)
Valid application IDs
3)
Transaction Set Syntax (ST/SE)
Valid data types
Valid data separators and terminators
Valid transaction and segment IDs
Overall data content and SE totals
Level 2 Edits
Level 2 edits check for compliance with the HIPAA Implementation Guide (see below). Errors
that occur are reported on the 864 Text Message Transaction (Level 2 Status Report).
©Anthem
1)
Variables based on the Implementation Guide
2)
Code Sets
3)
Looping Structures
4)
Situational Edits (inter-segment dependencies)
5)
Implementation Guide Balancing Rules
6)
Other Implementation Guide specific edits and requirements
7)
Member ID lookup
8)
Provider ID lookup
9)
Business Rules edits
10)
Trading Partner specific edits
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