Capital Deep Dive: Understanding an Electronic Claim
We've already discussed Claims and Remittance files at a high level, along with some analysis on other transaction types, so now we're going to highlight the actual contents of an electronic claim to understand what exactly providers are sending to payers. This information is key to understanding claims at their core.
Loops, Segments, Delimiters, oh my!
These files are considered EDI files, or, Electronic Data Interchange files, which are used across industries including our friends at X12.
Another term you may hear them referred to as is a "flat file", which essentially means that it's comprised of discrete lines of data with corresponding values - there are no variable references or cross-referencing between tables values.
Here's an example of an electronic claim (manually created, not real data):
These claim EDI files are comprised of loops, segments, elements, delimiters, and terminators:
Groups data into related sections. Looking at Example 1, the entire image is part of the Claim-level loop.
If you take note of Example 2, you can see the loops' hierarchical nature where it is possible for loops to live within loops. Item 1 in the blue box is a Provider-level loop, Item 2 in the green box is a second Provider-level loop, and Item 3 in the yellow box is a Service-level loop.
A loop is made up of one or more segments. A segment contains related elements in a specific order.
In Example 3 below, you can see the blue markers on each individual line.
A segment is made up of elements, or, discrete data points. Look in Example 3 to the green dashes for reference. Specifically note the marks in between the * marks: those are blank elements, meaning that data could be there, it just isn't for this file.
You would still count these blanks as an element - so the first mark between the asterisk would be "element 4".
A special character that delimits two elements from each other. There are three types of delimiters: element delimiters, component element delimiters, and repetition delimiters. In Example 3, note the red marks underneath the asterisk. This would be considered an "asterisk-delimited flat file". Other common delimiters are commas [,] and pipes [|].
Not Schwarzenegger; it's a special character that marks the end of a segment. In Example 3, note the pink mark - this is a tilde-terminated [~] flat file.
Inside an Electronic Claim Segment
Let's get a new example and break it apart:
This is the segment header and all segments have one. These are indicators for what type of segment it is. For example, the "SV2" means it is a service line segment (specifically for HB). An "NM1" would be for a name/identification segment, such as for a provider, or a "REF" would be for a reference number such as an NPI.
This is a simple data element. It represents a piece of information in relation to its segment. In this example, it's naming the revenue code.
This is a composite element that is comprised of two component elements (the HC and 81088). We can identify this as a composite element by the colon sign [:] serving as a component element delimiter.
You may be wondering "what if you have two segments with the same header, how do you tell them apart?" Good point! That's where qualifiers come in. Qualifiers generally preface an element within the segment in order to delineate what that element is. Qualifiers are used commonly and have their own respective category lists for their elements.
For example, take these two segments:
The FY and G2 are the qualifiers, signaling that their corresponding numbers are a Claim Office Number [FY] and Provider Commercial Number [G2], respectfully.