This section describes the standard formats used for TFM's Electronic Data Interchange (EDI). These standards are used for all types of data interchange between TFM and payers. It will also show you how to process claims for EDI submission.
| Standards: | X12 | HIPAA | |
| Claims: | Process | Submitting | Creating File |
| Responses: | Loading File | Interpreting File | |
| Mapping | |||
The ANSI standard format for all EDI is X12. It is the standard that is used in retail, transportation, automotive and other industries. X12 dictates the format of the data but not the content.
The Health Insurance Portability & Accountability Act(HIPAA) requires that all health insurance payers in the United States comply with the EDI standards for health care as established by the Secretary of Health and Human Services. The ANSI ASC X12 837 transaction set has been selected as the format to meet HIPAA requirements for the electronic submission of professional health care claims. The ANSI ASC X12 835 transaction set has been selected as the format to meet HIPAA requirements for the electronic transmission of remittance clarification and payment advice. TFM supports both of these transaction sets.
TFM manages claim records in three of four different phases of processing, new/unsubmitted, submitted, posted and transmitted. A claim progresses through each of these phases an may repeat the submitted and posted phase if it needs to be re-submitted with corrections.
A new claim is unsubmitted and not involved in EDI processing. Some claims will stay in this phase if your EDI trading partner will not accept it because of the payer type or other business reasons.
A claim that has been selected for EDI process is in the submitted phase. This phase is used to select claims for posting electronically versus filing a paper claim using a HCFA 1500 form.
A claim that has been posted is a claim that has been included in a ANSI X12 837 export file, in production mode. TFM has two modes for posting; piloting and production. When the Piloting flag is set in TFM preferences under the EDI tab, claims will be written to X12 files as test transactions and the claims will remain in the submitted phase.
A transmitted claim is claim that has been written to an X12 file and that file has been delivered to the your trading partner.
New claims can be submitted using the "Select Claims" option of the EDI menu in the main toolbar.
Any claim can be submitted or re-submitted using the "Submit" or "Re-Submit" button in the Claim Detail window.
TFM can create an ANSI X12 file containing claim transactions using the Post Claims menu item in the main EDI menu. Here you can select the claims you'd like to put into a file and click on the "Post" button.
The file you've created is in the directory specified as your exports directory in the preferences. The file is named '837_yyyy.ddd.hh.mm.edi', where 'yyyy' is the year, 'ddd' is the day of the year, 'hh' is the hour and 'mm' is the minute. The '837' represents the ANSI X12 transaction type of a claim. This file can be transmitted to your trading partner.
After transmitting your file to your trading partner, they will provide you with response file(s). If there are problems with the structure of the file, such as bad codes or missing data, they will create a file with 997 Functional Acknowledgment transaction(s) to inform you of what the problems were. If there is a problem with the actual claim data they will create a file with 277 Claim Status transaction(s). Finally when there are no problems with the claim, they will create a file with 835 Remittance Advice transaction(s) which will have payment information.
TFM will help you read and decode the transactions for correction and re-transmission. Selecting "Load Files" from the "EDI" menu presents a list of files in the EDI directory of the Imports directory which are X12 compliant. Click on the load checkbox for the file you want TFM to read. You will then be presented with a dialog which will show you each transaction as a folder with the decoded messages. Opening the folder will display the messages and related claims. You can click on any row inside a folder to select it. Then click on the "Go" button to open up the related object(s) in TFM.