The Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191 - known as HIPAA) http://cms.hhs.gov/hipaa/ enables health information to be exchanged electronically by means of EDI transactions (Electronic Data Interchange).
ANSI ASC X12N standard, Version 4010, was chosen for all of the EDI transactions except retail pharmacy transactions. Basically EDI transaction is a text file containing data in a specific ANSI ASC X12 format.
To comply with the transaction standards, health care Providers (the entities that originally submitted the claim/encounter, i.e. doctors or clinicians) and Payers (insurance carriers) may exchange the standard transactions directly or they may contract with a clearinghouse to perform this function. Clearinghouses may receive non-standard transactions from a provider, but they must convert these into standard transactions for submission to the Payers.
Basically, an EDI transaction is a text file (see example) containing data in a specific format.



In TPS2000 we implemented 2 types of EDI transactions:

• 837 Professional Health Care Claim (ASC X12 837 Version 004010X098). This is the form that is used to send the charges to the Payers.
• 997 Functional Acknowledgment (ASC X12 997 Version 004010X098). This is the form that is returned to you from the Payers.

1. The Health Care Claim Transaction for Professional Claims/Encounters (837) provides all necessary information to allow the destination payer to at least begin to adjudicate the claim.
2. The Functional Acknowledgment (997) transaction is used as the first response to receiving an 837. The 997 informs the 837 submitter that the transmission arrived. In addition, the 997 can be constructed to send information about the syntactical quality of the 837 transmission.

TPS 2000 automatically translates data from TPS2000 (claims, bills, patients information, carriers, etc.) into 837 Professional Claim file. Then using communication software provider sends 837 file to the Payer. In a few seconds payer sends back 997 Functional Acknowledgment telling to provider if the claim was accepted or rejected. If rejected then why (list of syntax or service data errors in the file)? The provider receives 997 file using Communication software. TPS 2000 automatically converts received file and marks bills sent to the Payer as "SA" – syntax accepted.

The communication protocol of exchanging data depends on payer. Some of them use modem-to-modem connection (kermit, X, Z-modem, protocols), some use internet connection (ftp protocol), etc.
EON Systems provides Communication software – TPS Communicator (modem-to-modem connection Kermit, X,Z-modem protocol) to be able to exchange via EDI transactions with Medicare FL. You can setup our software for other Payers as well. We tried to make this area easy-customizable for your convenience.

NOTE: There are 2 types of 837 file verifications on the Payers site.

1. Syntax control. Payer’s HIPPA software automatically checks all syntax errors (wrong symbols, missing data elements, etc.) in a file format and some service data (Sender/Receiver ID and Mailbox, 837 file control number, etc.). The final report is sent in 997 Functional Acknowledgment to the Provider.
2. Data control. Payer checks all claim data errors (wrong amount, patient data, insurance number, etc.) and notifies the provider if they got wrong data.