The lowdown on ICD-10 end-to-end testing


Getting ready for ICD-10 testing is going to require more than getting a good night's sleep and two No. 2 pencils.

To help you prepare, the Centers for Medicare and Medicaid Services (CMS) outlines the ICD-10 testing process for medical practices:

Provider submits:

  • Transaction through a practice management services (PMS), clearinghouse or payer
  • A request for patient’s eligibility for date of service through the ASC X12 270 transaction
  • Patient claim encounter ASC X12 837
  • A request for the claims status through an ASC X12 276 transaction

Vendor:

  • Receives claim encounter from PMS, provider or clearinghouse
  • Edits the patient claim encounter file
  • Transfers the patienct claim endounter file
  • Transfers the patient claim encounter o an ASC X12 837 claim submission file or stores it until the payer picks up the file

Payer receives:

  • Transactions from PMS, provider or clearinghouse
  • Inquiry on patient’s eligibility for date of service on an ASC X12 270 transaction
  • And accepts the ASC X12 837 file and transfers file into the claims processing system for adjudication
  • Inquiry for claim status through an ASC X12 276 transaction

Payer then sends:

  • Response to transaction to PMS, provider or clearinghouse
  • Response for patient’s eligibility through ASC X12 271 transaction
  • Acknowledgement (TA1, 999, 277CA) that the file has been accepted
  • The TA1 and 999 reflect technical problems that must be addressed by the software preparing the EDI transmission.
  • The 277CA reflects a data problem that must be addressed by resources in billing.
  • A claim status response through an ASC X12 277 transaction
  • A claim payment/advice through an ASC X12 835 transaction

Vendor:

  • Sends response to PMS, provider or clearinghouse that the file has been accepted
  • Receives acknowledgement (TA1, 999, 277CA) from the payer
  • Receives the ASC X12 835 transaction
  • Stores, transfers and sends an ASC X12 835 to the provider

Provider receives:

  • Transaction from PMS, clearinghouse or payer
  • Response for patient’s eligibility through an ASC X12 271 transaction
  • Acknowledgement (TA1, 999, 277CA)
  • Claim status response through an ASC X12 277 transaction (Receives the ASC X12 835 transaction)

Transaction definitions

  • ASC X12 270: Contacting a healthcare payer about a patient’s eligibility and benefits
  • ASC X12 271: Info from a healthcare payer about a patient’s eligibility and benefits
  • ASC X12 276: Request to healthcare payer about the status of a medical claim
  • ASC X12 277: Info about the status of a claim from healthcare payer
  • ASC X12 835: Medical claim payment and/or remittance info from healthcare payer.
  • ASC X12 837: Medical claim submitted to the healthcare payer.