Healthcare - Extending the 837

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Extending healthcare 837 for integrations and interfaces / This is the approved revision of this page, as well as being the most recent.
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Healthcare - Extending the 837

Description Guidelines for extending 837 to accommodate external information.
Version as of 8.7
Application Pega Smart Claims Engine for Healthcare
Capability/Industry Area Healthcare and Life Sciences



Introduction[edit]

The Smart Claims Engine's 837 transaction set is a format established to meet HIPAA requirements. This X12 transaction set contains healthcare claims data within the context of an Electronic Data Interchange (EDI) environment. This transaction is used to submit healthcare medical claims, billing information and/or encounter information from providers of healthcare services to payers, either directly or via intermediary billers and claims clearinghouses.

837 transactions can also be used to send external data to Smart Claims Engine (SCE) using the PWK segment. As seen in the table below, the PWK segment in the 837 is an existing repeatable segment, available in 2300 and 2400 loops, with two 80 character elements (PWK06 and PWK07) which can be used to send external information. This segment also captures code type to differentiate the information as supporting data.

Reference Designators Name Length
PWK01 Report Type 2
PWK06 Identification code 80
PWK07 Description 80

Use case examples[edit]

External information such as specific codes representing an error or warning or an external system override codes can be supplied on the inbound 837 files. Clients can also choose to extend these 837 to send external information to SCE to support :

  1. Claim resolution
  2. Claims adjudication
  3. Claim routing
  4. Information pass through to other systems

Sample scenario 1[edit]

Consider a scenario in which a healthcare application needs to send SCE a claim with an error code (for example, 51303) set due a member match issue on the claim in an external system. The following information would be included on the inbound transaction.

  • External System: S1
  • Record Type: Error
  • Code: 51303

This information would be sent on the PWK06 or PWK07 segment in the format shown below:

PWK*PG*****S1|Error|51303|||***

Record type PG (Claim support data) can be used to send the external data to SCE. The expected SCE action would be to capture the additional information submitted on the claim and crosswalk it to a SCE event code. This allows payers to leverage SCE's workflow and guided event resolution.

Sample scenario 2[edit]

Consider another scenario in which an external healthcare application sends claim information to SCE requesting the allowed amount to be overridden to $100 using reason code MAN01 . The following information would be included on the inbound transaction.

  • External System: S1
  • Record Type: Override
  • Code: AA
  • Value: 100
  • Field type : Currency
  • Reason code: MAN01

This information would be send on the PWK06 or PWK07 segment in the format shown below:

PWK*PG*****S1|Override|AA|100|Currency|MAN01***~

Record type PG (Claim support data) can be used to send the external data to SCE. The expected SCE action would be to capture the additional information submitted on the claim. This would help the claims examiners to take the needed action(s) to resolve the claim.

Note: If there are any properties whose value is more than 12 characters in length, then a work object in SCE will not be created, and an error response "Record type length should not exceed 12 characters" is returned.

Existing external information intake capability[edit]

SCE provides a design pattern which can be used and extended as needed to intake, store and parse external information. Out of the box, there are and two classes and six properties available to send and store external information. Clients can extend thee classes and add more properties as needed.

The two classes are:

  1. Data class: PegaHC-Data-Claimsupplement
  2. 837 integration class: PegaX12-Data-PWK_Paperwork

The six properties are:

Fields Example Type Limit
System External claim system Free form Text 12 characters
Record type Override, external edit, error, or warning Free form Text 12 characters
External code AA for allowable amount Free form Text 12 characters
Value $100 Free form Text 12 characters
Field type Currency Free form Text 12 characters
Reason code MAN01 Free form Text 12 characters

Process/steps to extend the capability to intake additional external information[edit]

  1. Step 1: Create the needed properties (for external data) for the data layer in PegaHC-Data-ClaimSupplement class.
  2. Step 2: Update the following to extend X12 parsing:
    1. DSS for choosing the needed delimiter for PWK.
    2. PWK segment parsing for external events and overrides.

External data in SCE[edit]

External information submitted for a claim may be viewed in the claims user interface by:

  • Clicking on Claim Header>Info from external system section.

Header external data.png

  • Clicking on Claim Line>Info from external system section.
    External data.jpg
  • External information can be submitted in SCE by:
    • Clicking on +New > Claim Header (or Claim Line) section.
    • Clicking on Test Suite > Test Claim > Claim Header (or Claim Line) section.

Reference materials on Community[edit]

For more information, see Claims API integration