Real-Time Transaction Glossary 10/01/2014

Transcription

1 WEDI Dental Workgroup Real-Time Transaction Sub-workgroup Real-Time Transaction (RTA) White Paper Real-Time Transaction Glossary 10/01/2014 Workgroup for Electronic Data Interchange 1984 Isaac Newton Square, Suite 304, Reston, VA T: //F: Workgroup for Electronic Data Interchange, All Rights Reserved 1

2 Disclaimer This document is Copyright 2014 by The Workgroup for Electronic Data interchange (WEDI). It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. If you require legal advice, you should consult with an attorney. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by the Workgroup for Electronic Data Interchange. The listing of an organization does not imply any sort of endorsement and the Workgroup for Electronic Data Interchange takes no responsibility for the products, tools, and Internet sites listed. The existence of a link or organizational reference in any of the following materials should not be assumed as an endorsement by the Workgroup for Electronic Data Interchange (WEDI), or any of the individual workgroups or sub-workgroups of the WEDI Strategic National Implementation Process (WEDI SNIP). Document is for Education and Awareness Use Only 2

3 Table of Contents I. PURPOSE AND SCOPE... 8 II. BACKGROUND III. KEY TERMINOLOGY IV. ACKNOWLEDGEMENTS

4 I. Purpose and Scope This glossary should be used only in conjunction with the RTA Business Process Flow and RTA Technical Communications Documents drafted by the WEDI Dental Workgroup in 2013, in defining the terms used in those documents. II. Background In 2012, WEDI Dental Workgroup was formed and one of its primary objectives was to update a draft of the RTA Whitepapers. The WEDI Dental Workgroup has met on a bi-weekly basis and has created a dental-specific RTA White Paper, which includes a Business Process Model, Technical Communications document and Glossary. The Workgroup adopted the format and framework from the work based on collaboration started in 2007 between WEDI and X12. In 2007, WEDI and X12 began collaborating on an initiative to bring RTA to the health care industry. WEDI and X12 hosted a conference in February 2007, which emphasized the need for RTA and the environment that presented both barriers and catalysts for moving to RTA. Discussions focused on the need to develop business process models, define a common language, set communication protocols, identify security and privacy needs, research the topic of Health Information Portability and Accountability Act (HIPAA) waivers, and market RTA. The six priorities identified at the conference were turned into joint WEDI-X12 work groups as part of an overall RTA initiative. The workgroup began its work in the fall of 2007, conducting interviews with provider groups, re-pricing organizations, health plans and clearinghouses and presented its findings to many diverse organizations. During the summer of 2008, both WEDI and X12 approved the workgroup s preliminary models and transaction recommendations with comments. The decisions and workflows from this workgroup have served as the baseline for several other workgroups in the joint WEDI-X12 RTA initiative. The WEDI Dental Workgroup updated and submitted the revised RTA documents to the WEDI Board, which approved the white papers for publication in August

5 III. Key Terminology Acknowledgment: An electronic answer or response in return to a submitted RTA transaction. Attachment: Additional information to support an RTA Transaction. Batch Claims Submission: Electronic claims submission in which the provider submits one or more claims to the clearinghouse or payer and the sender does not remain connected while the receiver processes the transactions. Claims Adjudication: The process through which a processor applies coverage, benefit, medical and contract guidelines to a specific claim in order to determine the applicable reimbursement by the health plan or the cause for rejection/denial. Related Terms: Claim Denial, Finalized Claim Note: Do not confuse a zero claim denial with a zero payment which can be the result of other payer or patient responsibility. Claim Denial: The final claim adjudication disposition resulted in non-payment of the claim based on business rules as defined by the contract. A business contract can be between the provider and payer or member and payer. Do not confuse a zero claim denial with a zero payment which can be the result of other payer or patient responsibility; payment of zero does not mean it s been denied. Claim Level Information: Data that pertains to the entire claim, including all services reported on the claim. Claim Pended: The claim was suspended during claim adjudication due to business, medical or utilization rules that require additional information in order to complete claim adjudication. This results in claims leaving the RTA process and being handled as part of batch claims processing. Claim Rejection: The process whereby a received claim is not accepted for claim adjudication due to either format issues, or payer specific business edits. Claim Status Category Code: A code that indicates the category type of the status for a specific claim. Related Terms: Claim Status Codes, Entity Identifier Codes Claim Status Code: A code provided by the payer to the provider specifying the status of a claim that was submitted by the provider to the payer for processing. Related Terms: Claim Status Category Codes, Entity Identifier Codes Contractual Obligation: A determination that a specific part of the submitted charge from a claim or service line is not collectible by the provider from the patient due to either a regulatory requirement or specific terms of the provider s contract with the health plan. 5

6 Coordination of Benefits (COB): The process whereby multiple health plans determine their responsibility and processing order for a specific claim when all may share some responsibility due to separate relationships with the patient and or the provider. Note: At the time of publication of this document COB is not being considered for RTA. Co-Insurance: The percentage of the amount allowed by a health plan for a specific claim or service that the patient is responsible for paying as part of the cost sharing terms of the contract between the health plan and the patient or subscriber. For example, the patient or subscriber pays 20 percent toward the charges for a service and the employer or insurance company pays 80 percent. Related Terms: Co-payment, Deductible Co-Payment: Co-payment is a predetermined (flat) fee that an individual pays for health care services, as part of the terms of the contract between the health plan and the patient or subscriber in addition to what the insurance pays. Related Terms: Co-insurance, Deductible Destination Payer: The payer to whom the claim is being sent for adjudication. Deductible: The amount an individual must pay for covered health care expenses before insurance (or a self-insured company) considers the remaining costs. Related Terms: Co-insurance, Co-payment Duplicate Claim: A claim that is considered by the payer to have been previously submitted for adjudication. Entity Identifier Code: A code identifying the type or category of an organization, a physical location, property, or an individual, by function within the context of a health care claim. The list of allowed codes is included in ASC X12 Implementation Guides that utilize this data. Related Terms: Claim Status Codes, Claim Status Category codes Estimator: A process employed by a payer to calculate an estimated payment to be paid to the provider for the services reported on the claim. The final adjudication and subsequent payment may differ from the response provided at the time of the estimation. Related term: Predetermination of Benefits Finalized Claim: A finalized claim is one that has been completely adjudicated. Finalized claims are either denied or paid. Related terms: Claim Denial, Claim Adjudication Health Care: Care, services or supplies furnished to an individual and related to the health of the individual. Health Care includes the following: 6

7 (1) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care; and counseling; service; or procedure with respect to the physical or mental condition, or functional status, of an individual or affecting the structure or function of the body. (2) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription. (3) Procurement or banking of blood, sperm, organs, or any other tissue for administration to individuals. Source: Health Insurance Reform: Standards for Electronic Transactions; Announcement of Designated Standard Maintenance Organizations; Final Rule and Notice. Federal Register 65:160 (17 August 2000) p Health Care Claims or Equivalent Encounter Information: The transmission of either of the following: (a) A request to obtain payment or an estimate of prospective payment, and the necessary accompanying information from a health care provider to a health plan, for health care. (b) If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purposes of reporting health care. Health Care Provider: A provider of services as defined in section 1861(u) of the Act, 42 U.S.C. 1395x(u), a provider of medical or other health services as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s), and any other person or organization who furnishes, bills or is paid for health care in the normal course of business. Source: Health Insurance Reform: Standards for Electronic Transactions; Announcement of Designated Standard Maintenance Organizations; Final Rule and Notice. Federal Register 65:160 (17 August 2000) p In-network Provider: Providers or health care facilities that are part of a health plan's network of providers with which it has negotiated a discount. Out-of-network Provider: A provider or health care facility that is not contracted to participate in patient s specific Provider Network. Patient Responsibility: The portion of the payment for a claim or service that a payer deems to be the patient s liability. Patient Responsibility may be dictated by contractual obligations and/or regulatory requirements and it typically includes co-insurance/co-payment, deductible, and out of network penalties Related terms: Co-insurance, Co-payment, Deductible Predetermination of Benefits: A pre-service request for a statement of what benefits may be payable under the health plan, provided everything remains the same (e.g., eligibility, plan, services rendered) as reported in pre-determination at the time the service is actually rendered. The predetermination request would include all data necessary to fully adjudicate a claim except for date(s) of service. Pretreatment Estimates: A pre-service request for a statement of what benefits may be payable under the health plan, provided everything remains the same (eligibility, plan, services rendered) as reported in pretreatment estimate at the time service is rendered. The 7

8 pretreatment estimate request includes data necessary to fully adjudicate a claim except for date(s) of service. Provider Network: A group of providers or health care facilities contracted to provide services to insurance company s customers. Real-Time (RT) Claim Advice: The RT Claim Advice is a specific implementation of the existing 835 Health Care Claim Payment/Advice transaction. RT Claim Advice is a term used to define a special version of the 835 to respond to a real-time claim. With RT Claim Advice, there is no receipt of payment information; it is sent afterwards in a separate transaction. Real-Time Adjudication (RTA): The Real-Time Adjudication Process (RTA) is the process of a single claim being submitted by a provider to a payer. The payer fully adjudicates the claim to its final disposition. The payer responds to the provider advising of denial reason(s) or amount to be paid, patient responsibility and adjustments and explanations. The whole process is completed in a single communications session that is established and remains open and active until the adjudicated transaction is received by the entity initiating the communication session. Note: The terms real-time adjudication and real-time claims adjudication are the same. The Real-Time Adjudication Process (RTA) is the process of a single claim being submitted by a provider to a payer. The payer fully adjudicates the claim to its final disposition. The payer responds to the provider advising of denial reason(s) or amount to be paid, patient responsibility and adjustments and explanations. The whole process is completed in a single communications session that is established and remains open and active until the adjudicated transaction is received by the entity initiating the communication session. Processed Response yes RT Claim Requestor Submission via Web Services Real Time system available? Yes Process Transaction System Unavailable Response No No Note: The terms real-time adjudication and real-time claims adjudication are the same. Timely Processing? Service Level Information: Data that pertains to a specific service or procedure reported on a claim. Related term: Claim Level Information 8

9 IV. Acknowledgements Ornela Besho, American Dental Association Tom Burden, Delta Dental of Idaho Patrick Cannady, American Dental Association Maureen Croker, Delta Dental Plans Association Tom Drinkard, Delta Dental of Virginia Trish Edler, Tesia Clearinghouse, LLC Theresa Jansen, United Concordia Companies, Inc. Kathy Jönzzon, Delta Dental Plans Association Tom Mort, Dental XChange Jean Narcisi, American Dental Association Scott Wellwood, Dental XChange 9