The Health Insurance Portability and Accountability Act (HIPAA) recently introduced claims attachments into the group of HIPAA transactions. These transactions are based on the X12 version 4050, rather than the 4010 version.
A health care claim attachment conveys supplemental information about the services provided to a specific individual to support evaluation of a claim before it is paid.
The goal of health care claims attachments is to make the process of submitting and adjudicating health care claims more effective and efficient by providing a structured and standard means of requesting clinical/supporting data for health care claims or encounters. Claims attachment usage includes:
Supporting health care claims adjudication
Assessing prior authorization
Validating policies and meet standards
Providing post-payment review
Mitigating fraud and abuse
Contributions to the ultimate outreach recommendations included determining the most frequently used attachments; considering the attachments where HL7 messages already existed or were in development; a need to standardize the questions payers ask; and the use of LOINC codes.
LOINC stands for Logical Observation Identifier Names and Codes and comprises universal names and ID codes for identifying laboratory and clinical test results and other information meaningful in claims attachments.
LOINC is freeware owned by Regenstrief Institute and the Logical Observation Identifier Names and Codes (LOINC) Committee.
Using LOINC allows for specific questions to be asked, when required, as many of the codes required for claims attachments are already present.
Figure 2-1 illustrates the business flow solicited model for claims attachments.
Figure 2-1: Business flow solicited model
Figure 2-2 illustrates the business flow unsolicited model for claims attachments.
Figure 2-2: Business flow unsolicited model
As illustrated in Figure 2-3, a 277 asks for attachments or components by sending LOINC, whereas a 275 sends components consisting of answer parts identified by LOINC.
Figure 2-3: Structure of claims attachments
Sybase HIPAA Accelerator 6.0 includes the new claims attachments, along with rules spreadsheets, which document the changes to the compliance maps.
These spreadsheets document the Implementation Guide (IG) map rules and conditions and enable users to quickly find the edits for a particular IG requirement.
