One of the most confusing parts of medical billing and the electronic submission of claims is the batch. Most billers don't understand why you even need to have multiple batches. Can't all the claims just go inside one package and get shipped? Well, with paper, yes. But if you're a big billing house and billing for a number of providers, then the process isn't that simple. Before we go into our detailed review of the YA0 record, an explanation of batches is probably in order.
Because of the way claims are paid, especially by the big insurance companies or government agencies, keeping track of batches is very important. Why? Because when insurance companies cut their checks for the claims, they are cut and paid to the provider, not to the patient, unless designated to do so. If a large billing house is representing multiple providers, they may very well submit a large claim file representing multiple providers. These providers are identified in the BA0 record in field number 2, positions 4 - 18, which is the provider ID. This record designates the beginning of that batch and this field designates the provider associated with that batch. If the biller wants to bill a second provider, then another BA0 record must be used so that the insurance carrier knows who the second carrier is. Otherwise, the check will end up getting cut for one provider. This can obviously cause a lot of problems.
In order to make sure this doesn't happen, most electronic billing software has what is called a multiple provider option. What happens is that somewhere in the system, a list of providers is kept in a large table. In very large billing houses, this table can contain hundreds of providers. Each one is given an ID number and a table number. The ID number is assigned by the governing agency. The table number is assigned by the software. Each patient in the system is assigned to a provider. When that patient's claim file is pulled, a cross match is made between the table number of the provider that is entered in the patient file and the provider number itself. If the provider number is different from the previous provider number that was billed, a new BA0 record is created. Before this is done, however, the YA0 record is created to sum up the previous batch for the first provider.
This is of course greatly simplified, but hopefully you get the general idea. Once the YA0 record is created and filled in and the new BA0 record is created, your multiple batch system has just gone into effect. You simply repeat this process for each provider. The hard part for billers is making sure that the provider table ID is properly entered for each patient. Otherwise, the wrong provider will be paid for the services rendered.
In our next installment of medical billing and the electronic transmission of claims using NSF 3.01 specifications, we'll be covering the YA0 record in detail.Medical Billing - Multiple Batches