HIPAA Accelerator Guide

10.2
- 10.5.3
- 10.5.0
- 10.4.0
- 10.2.3
- 10.2.2
- 10.2.1

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Claim Level Processing and Reconciliation

For HIPAA messages 837I, 837D, 837P, 277CA, and 835, Claim level information is also extracted. The file is processed in the following steps:

Split the file into separate claims

Create a DX event for each claim

Add the corresponding attributes to the event

Calculate totals (number of claims and total amounts)

Add the totals as attributes to the transaction's event

The correlation between inbound 837 and outbound 277CA and 835 is reflected in these transitions.

When inbound 837 messages are processed at claim level, a correlation flag is created. The event status is set to 'Submitted' and the reconciliation flag is changed to 'Pending'.

When the corresponding outbound 277CA claim event is created, the status of the inbound 837 DX event is changed accordingly. The reconciliation flag is changed to 'Complete'.

If the status was changed by the 277CA to '277 Claim Accepted', another correlation flag is created and its status is changed to 'Pending'.

The status of the correlation flag will be changed to 'Complete' when outbound 835 claim is created. The status of the Claim will then be changed to 'Paid'.

Event statuses

DX Event Status	Description
Submitted	837i claim was submitted
277 Claim Rejected	Claim was rejected by 277CA HIPAA message
277 Claim Accepted	Claim was accepted by 277CA HIPAA message
Paid	Claim paid with 835 HIPAA message

Event types

The event type format is '<Hipaa document identifier> Claim '. For example, the event type will be '837 Claim
' for HIPAA document 837I.

Event attributes

DX Event Attribute Name	Transaction Type	Loop ID	Segment ID	Element ID	HIPAA Name
Claim_Id	837	2300	CLM	R01	Claim Submit Identifier
Claim_Monetary_Amount	837	2300	CLM	R02	Monetary Amount
Claim_Id	277CA	2200D	TRN	R02	Reference Identification
Claim_Monetary_Amount	277CA	2200D	STC	R04	Monetary Amount
Health_Care_Claim_Status_Category_Code	277CA	2200D	STC	R10	HEALTH CARE CLAIM STATUS
Claim_Id	835	2100	CLP	R01	Patient Control Number
Claim_Paid_Amount	835	2100	CLP	R04	Claim Payment Amount
Claim_Submitted_Amount	835	2100	CLP	R03	Total Claim Charge Amount
Claim_Patient_Responsibility_Amount	835	2100	CLP	R05	Patient Responsibility Amount

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Table of Contents

HIPAA Accelerator Guide

HIPAA Accelerator Guide

Claim Level Processing and Reconciliation

Claim Level Processing and Reconciliation

Event statuses

Event types

Event attributes