HIPAA-compliant Transactions

All of our transactions are compliant with electronic data interchange (EDI) specifications published by the Accredited Standards Committee (ASC) X12. We currently generate transactions compliant with 4010 standards and are in the process of updating our software to be fully compliant with the new 5010 standards. The government has mandated that all transactions submitted on Jan-01-2012 and later be compliant with 5010. (Dec-01-2011 update: Final compliance date has been pushed out by the federal government and NY State to Apr-01-2012. We are presently using NY's Provider Test Environment to submit 5010 claims in parallel with live 4010 claims for existing clients. We plan to switch all clients to 5010 by Jan-31-2012). Providers can submit data in any convenient format to our secure extranet, where any necessary conversion occurs automatically to create eligibility requests and claims. Here are the transactions we support:

270 Eligibility, Coverage or Benefit Inquiry

We can generate an eligibility request from your data in any format.

271 Eligibility, Coverage or Benefit Response

Information from response files is formatted to meet your needs. We can, for example, provide responses as Excel spreadsheets to simplify your sorting and searches.

278 Service Authorization (SA) (4010 only)

This transaction was eliminated on Jul-21-2011. At that time, the Eligibility Response (271) began to report "At Limit" information for any applicable Service Categories. UT counts now increment based on claim adjudication instead of SA reservation of units.

278 Prior Approval (PA) Request (5010)

The 278 PA transaction will provide the ability to request changes for existing authorizations: 1) Request extensions for a previously approved service, 2) cancel an approval or 3) revise/cancel a previously approved service line.

837 Health Care Claim

We can generate 5010-compliant Institutional and Professional claims from your proprietary data.

277 Health Care Claim Status / Acknowlegement

This is a response to a submitted 837 claim. Under 4010, a U277 ("unsolicited" 277) accompanies the 997 response file to indicate claims rejected from the 837 batch file that has been admitted to the adjudication process. Beginning 07-21-2011, specific denial reasons for claims rejected before entering the adjudication system were reported in the U277, but no longer appeared in the remit (paper or electronic 835). This is an advantage to the provider, since denial information is reported within hours of claim submission instead of weeks later on the remit. Under 5010, the 999 response replaces the 997, and the accompanying 277CA (Claim Acknowlegment) is received for every submitted file; the 5010 277CA contains a response for every claim in the 837 to indicate whether or not each claim is adjudicated along with specific reasons for any denials. Compliant Data Systems creates detailed acceptance/denial reports for billers/providers from the 277 transactions.

835 Health Care Claim Payment / Remittance Advice

The 835 Supplemental file lists Denied and Pended claims. Pre-adjudication denials were removed from the 835S on Jul-21, at which point they began to be reported earlier in the U277 (4010) or 277CA (5010). Only Pends are reported in the 835S after Jul-21. If claims are accepted into adjudication, as indicated in the 277, they may still deny - if they do, claim adjustment reason codes (CARCs) are reported in the 835. CDS converts electronic remits (835 and 835 Supplemental) into human readable reports - either PDF or spreadsheet.