Claim Transaction definition
Claim Transaction means a medical, surgical, laboratory, radiology, therapy or other service claim or encounter, whether for a Covered Service or any other service or product, submitted to Customer by a Provider detailing services or products provided by such Provider to an Enrollee.
Claim Transaction means (a) a "Claim Submission," comprised of the electronic submission by a Plan Provider, pharmacy or laboratory of a claim for services to a single patient on the same date of service or for an RX Order or Diagnostic Order, limited to six transaction lines, and involving for each Claim Submission (i) edit checking based on Kaiser Message Specifications, (ii) duplicate claims checking for both the service and date of service for all claims submitted through the Cymedix Software and (iii) match checking of Provider ID, physician ID, specialty and location for correlation under the appropriate Kaiser contract, with the resubmission of a Claim Submission by a Plan Provider or other Healthcare Participant resulting from any error not caused by the Cymedix Software to be treated as a separate Claim Submission, and (b) a "Claim Acknowledgment," comprised of an electronic acknowledge of receipt by Kaiser or its designated Plan TPA of the Claim Submission, together with an explanation of any rejection for failure to satisfy required components, expressed in mutually acceptable codes included in the Kaiser Message Specifications.
Claim Transaction means only those transactions set forth in item (1) of Exhibit H. An "EDI Transaction" means a Transaction accomplished through electronic data interchange.
Examples of Claim Transaction in a sentence
The SDMC II database is queried for service lines from approved claims that are claimed with the following Electronic Data Interchange Health Care Claim Transaction Set (837) data elements: • A Demonstration Project Identifier (DPI) set to “KTA”, or • Healthcare Common Procedure Coding System (HCPCS) codes for Intensive Care Coordination (ICC) or Intensive Home Based Services (IHBS).
Claim, Transaction, and Notes data sent to the Origami FTP site must be encrypted using at least 128 bits.
More Definitions of Claim Transaction
Claim Transaction means any transaction for which a control number has been assigned for processing through the Assuming Company's claims system and that is processed to a final disposition status including payment, non-payment, partial payment, and payments attributed toward deductibles. A Claim Transaction for Professional services shall not exceed ten (10) input lines, and a Claim Transaction for Facility services shall not exceed twenty (20) input lines. Each additional segment of ten (10) input lines or less in the case of Professional services, or twenty (20) input lines or less in the case of Facility services counts as an additional Claim Transaction. Claim Transaction shall not mean any transaction resulting from error identification and correction, from adjustments due to utilization review or other coverage information, from duplicate submissions by health care providers, or from retroactive benefit adjustments.