Health Care Flow

HEALTH CARE FLOW

Please follow the details:


Health Care flow means Generally we follow like this as given below

1 Provider
2 Insurance
3 Clearing Mediate
4 Subscriber


Dependents


1) Provider : Provider means nothing but Hospitals/Clinical Laborites

2)Subscriber/Dependents: Subscriber/Dependents means nothing but patients or
Dependant patients

3)Insurance: Insurance means nothing but Insurance Policy

4)Clearing Mediate: Clearing Mediate means nothing but consultant between Provider
And Insurance


Description: As per as USA Government Act , who ever wants to get treatment from Hospitals/Clinical laborites (Provider) before that Subscriber/Dependents must and should get Insurance policy(It is a Mandatory) then only Hospital/Clinical Laborites can start treatment , without any Insurance Policy , provider won’t give any treatment.














First step

Before going to treatment, subscriber have to get insurance policy from insurance , what ever subscriber getting insurance or going to get insurance we call as a Benefit enrollment means 834 transaction, so first we will sending 834 transaction to insurance, what ever it, it will start from subscriber


1) 834: Benefit Enrollment Transaction
So first we will start from 834 transaction in health care , after applying subscriber for insurance policy, Insurance give some USN number , what ever Insurance replying to subscriber we don’t say any transaction.(only what ever subscriber doing that is only we call transaction here)

Second Step

After getting subscriber insurance policy, subscriber does go to provider (Hospital/laborites) here also what ever subscriber doing we don’t call any transaction




Third Step

After getting (subscriber) insurance policy and treatment from provider, provider send one transaction to Insurance i.e. 270 : Eligibility status request means here provider sending details to insurance weather subscriber having insurance policy or not?

270: Eligibility Status Request


some times provider using clearing Mediate, because some times provider could be busy, like what ever right now going in IT field, the corporate companies directly not recruiting any kind jobs their consulting from consultants, so like this provider also some times use this clearing mediate


Fourth Step

Provider already sent request for subscriber details weather the subscriber having Insurance policy or not ? what ever Insurance getting the request data after that Insurance sends response i.e. 271 : Eligibility status Response to provider weather subscriber/patient having insurance policy or not?

271: Eligibility Status Response


some times provider using clearing Mediate, because some times provider could be busy, like what ever right now going in IT field, the corporate companies directly not recruiting any kind jobs their consulting from consultants, so like this provider also some times use this clearing mediate

Fifth Step

After receiving Response from Insurance company, provider now sends Health care claim status for regarding bills and financial issues, means provider sends roughly figure what ever expenses done for subscriber ; that is here we call 837: Health Care Claim Status


837:Health Care Claim Status



Sixth Step

After sending rough intimation to Insurance 837:Health Care Claim Status , here provider sends again 276:Health Care Claim Status Enquiry for regarding status enquiry


276 Health Care Claim Status Enquiry







for every transaction we are sends acknowledgement i.e. 997:Functional Acknowledgement card

Seventh Step

After receiving 276:Health Care Claim Status, Insurance sends 277:Health Care Claim Status Response for regarding status response


277 Health Care Claim Status Response




for every transaction we are sends acknowledgement i.e. 997:Functional Acknowledgement card

Eighth Step

After sending and receiving 276:Health Care Claim Status, 277:Health Care Claim Status Response again provider sends 820 Payment Order for regarding Payment orders


820 Payment Order




for every transaction we are sends acknowledgement i.e. 997:Functional Acknowledgement card

Ninth Step

After receiving Payment order transaction Insurance pays that payment that is 835 Payment & Remittance Advice


835 Payment & Remittance Advice




for every transaction we are sends acknowledgement i.e. 997:Functional Acknowledgement card

so what ever it health care generally follows above processor,

1) 834
2) 270
3) 271
4) 837
5) 276
6) 277
7) 830
8) 820