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Pro837™ Edit Hierarchy

  • Type 1: EDI File Structure Syntax – Check for the presence of required X12 data segments. Verify reported data segments are X12 compliant. Validate data element attributes (e.g. maximum element lengths are not exceeded; date fields are properly formatted, etc.) with X12 rules.
  • Type 2: HIPAA-Specific Syntax – Check reported data segments, elements, codes and qualifiers for compliance with 837-specific implementation guidelines. This also includes checking for intra-segment situational data elements (e.g. if element A is populated, then element B must also be populated).
  • Type 3: Balancing Amounts – Check each claim for balanced field totals where appropriate (e.g. the total claim amount must equal the sum of all line item amounts).
  • Type 4: Situational data – This includes the validation of situational data fields relative to other data reported in the claim. Many data segments and elements are required only under certain conditions (e.g. an accident date must be reported if an accident code is reported; the accident state must be reported if an auto accident is reported; a revenue code requires an admitting diagnosis or patient reason for visit, etc.).
  • Type 5: External code sets – Validate all external code sets such as CPT/HCPCS/CDT codes, place of service codes, ICD9 diagnosis and procedure codes, DRGs, revenue codes, occurrence codes, treatment codes, condition codes, value codes, patient status codes, taxonomy codes, zip codes, state-zip code combinations, et al. Validation includes testing for appropriate usage within the claim and for coding guidelines that apply to the specific code set. Some examples: modifiers, diagnosis and place of service codes must be appropriate for procedures; procedure and diagnosis codes must be valid for the reported dates of service; correct use of add-on procedure codes; procedure and diagnosis codes appropriate for the patient’s age and gender; Correct Coding Initiative (CCI) compliance; occurrence codes are appropriate for the type of bill; diagnoses are coded to the proper level of specificity; the reported primary diagnosis is a valid primary diagnosis, etc.
  • Type 6: Lines of service – Check for requirements that apply only to specific lines of business/service. Specialized services such as ambulance, chiropractic, podiatry, home health, skilled nursing facilities, durable medical equipment (DME), etc. have specific claim editing requirements in addition to those mentioned above (e.g. ambulance service claims must always include ambulance transport information).
  • Type 7: Payor specific – Check for payor-specific published and non-published requirements that, if not met, can lead to claim rejections prior to adjudication and suspended or denied payments after adjudication. This includes validating procedure and diagnosis codes with published LMRPs/LCDs.







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