Medical billing, depending on whether you are billing paper claims or electronically, is a totally different animal for each. Electronic claims have one thing that paper claims don’t have. And while they pay faster, thus the reason for billers to bill electronically, they can also be a royal pain in the backside because of all the restrictions and requirements. One of the strictest of these requirements is claim records hierarchy. We’re going to briefly explain that hierarchy in this installment, as a detailed explanation will probably leave you confused and running for the nearest exit.
If you’re billing claims by paper you simply take each paper claim, stick it in an envelope and leave it in the hands of your trusted mailman. Not so with electronic claims. Not only does the envelop of electronic claims have to be properly addressed, but it better have every piece of paper in just the right place and totals for everything from how much you’re billing to how many pieces of paper you have. The key to all this is that it all has to be in a certain order.
To simplify this process, think of your claim file as a wrapper for sticks of gum. Each individual stick of gum is a record specification such as your CA0, DA0, EA0, FA0, G and H records. These are your records for each individual patient. Any claim file can have as many patients as you like stuffed into it. This means that you can have an infinite number of C, D, E, F, G and H records. However, each patient’s records must all be together. So, to keep this simple, if you have two patients in your file, you would have their records transmitted in this order; C, D, E, F, G and H records for patient 1 and then C, D, E, F, G and H records for patient 2. If a C record from patient 2 ends up falling with the C, D, E, F, G or H records from patient 1 then the whole batch will fail and nothing will get paid.
But, this isn’t the end of it. For each patient, there is a trailer record. The trailer record for the patient is the XA0 record. This record gives the totals for that particular patient. So there needs to be an X record for patient 1 and one for patient 2. This record MUST come after the H record of each patient. Then, there is a trailer record for the batch, which is all the patients submitted in the batch. This is the YA0 record and MUST come after the last X record in the batch.
Finally, we have the outer wrappers, which are the AA0 and BA0 records at the beginning of the file and the ZA0 record, which is the file record trailer at the end of the file. This record gives the totals for every record in the whole claim file. So the whole hierarchy for a two patient claim file would have the following record series, AA0, BA0, CA0, DA0, EA0, FA0, G record, HA0, XA0, CA0, DA0, EA0, FA0, G record, HA0, XA0, YA0, ZA0.
If these records are not transmitted in exactly this sequence, the whole file will be rejected. Obviously, this is quite simplified as there can be multiple items and payers for each patient. But you get the general idea.
When it comes to medical billing, records hierarchy can be a real nightmare, especially if it’s not done correctly.