Electronic Billing (837) Business Rules

Overview

Business Rules are an integrated feature of 837Direct that enforces technical requirements on each claim that might prevent the claim from being processed and paid. 837Direct has over 7000 Business Rules in place that have been developed and refined through 20 years of electronic claims processing experience. These rules are grouped into categories based on their origin and the order that they are applied to each claim. These categories are HIPAA, Receiver, Payer, OCE and CCI. These Business Rules are constantly modified and documented as these requirements evolve to maintain a process that reflects current industry standards.

HIPAA

Our HIPAA edits are designed to enforce the current data requirements of the ANSI 837 electronic claim format which is the mandated industry standard for healthcare claims under HIPAA.

Receiver

Receiver is our term for any entity that receives ANSI 837 claim files. This could be an insurance company (Payer) or a clearinghouse that processes claims for multiple payers. At this level, we provide Business Rules that apply to all claims sent to a Receiver that apply to all claims they receive and are not specific to individual Payers.

Payer

These are Business Rules that are specific to certain Payers. These rules are obtained through documentation provided by the Payers regarding their rules for “clean” claims and by the documentation of adjudication errors or denials reported by our customers. When claims fail at this level, we work with our customers to rapidly deploy new Business Rules to prevent future similar problems for all healthcare providers and their agents that use 837Direct. This is the level that includes the most Business Rules and those that are most often created or modified based on changing Payer requirements. It is the quality and validity of this portion of 837Direct that separates us from our competition and provides the greatest value to our customers in meeting their revenue cycle management goals.

OCE

OCE is the Medicare Outpatient Code Editor. This is software provided by CMS that we have incorporated into the 837Direct application. CMS updates this system quarterly to include new criteria required by Medicare regarding Business Rules for OPPS (Outpatient Prospective Payment System) claims.

CCI

CCI is the Correct Coding Initiative, like OCE, these edits are provided by Medicare quarterly and reflect the current rules regarding specific charges and codes allowed on Medicare Part B claims.

See what our customers are saying!

"We started out with one 45 bed hospital. But as we have grown, MEDTranDirect has accommodated our needs. Today we use 837Direct to do billing and process electronic remittances for 2 hospitals, totaling 70 beds and 9 clinics covering 2 states. We are extremely pleased with its ease of navigation and flexibility. It interfaces well with CPSI (practice management system). We are especially happy with the support we receive from the technical support staff. I frequently recommend the product to others and will continue to pass MEDTranDirect’s name around."

Beth Hill - Director of Patient Finance, Ozarks Community Hospital