Navigation:  Claim Adjudication > Concepts

From the beginning of HIPAA and healthcare EDI it was envisioned that all transactions between healthcare entities can be modeled in the EDI implementation guides.

The 837 formats for example are designed to accommodate every sector of healthcare services. The 835 can in every detail explain the reimbursement process and the adjustments taken from the charges a provider puts forward.

With the adjudication module of the HIPAA Claim Payment Master we are using the capabilities of the HIPAA Premium Payment Master to store EDI claims in a database and give the ability to adjudicate and pay those claims. Critical to this model is the ability to manually perform all the operations that the HIPAA model contains to adjudicate claims. Once claims are adjudicated they can be bundled by payee, which is usually the billing provider and paid including the creation of the payment CCD+ transaction and the remittance advice in the 835 format.

At the same time a claim status is assigned to each claim or service line and the 277 claim status response can be given automatically with our HIPAA Claim Status Responder and HIPAA RealTime Server.

The paid claim information can also be forwarded to other down stream payers with the post adjudicated claim format X298, X299 and X300.

The goal is to have total claim management within HIPAAsuite appllications and perform out of the box the most important transactions of a health indemnity organization.