HL7 Messages in Healthcare Billing Environments

Every healthcare environment bills for services provided. The goal of billing is to increase reimbursement in a timely fashion. How does the HL7 Standard help in this endeavor? Automating clinical data delivery through HL7 interfaces provides accurate information quickly to the billing department.

When transferring patient’s billing information through HL7 messaging, it is helpful to know some of the key segments in which to find the data.

PID: Patient Information
PV1: Visit Information (DOS)
FT1: Financial Transaction
IN1: Insurance Information
IN2: Additional Insurance Information
IN3: Additional Insurance Info, Certification
GT1: Guarantor
AUT: Authorization Information

A better understanding of the HL7 messages used in various billing environments may help demonstrate the possible automation and healthcare integration capabilities.

1) In acute care hospitals, the billing department is typically in-house. As a patient is treated, the clinical data is transferred to the appropriate departments throughout the hospital, including billing. The main HL7 messages transferred to billing are:

ADT = Patient demographics
DFT = Detailed financial transaction
ORU = Observation result unsolicited

Below is an example DFT message that shows the addition of a test, Lipid Panel, to a patient’s bill:

PID||3|82828||Simpson^Margaret^^^Mrs.||19650525|F|||12 Maple St.^^Springfield^OH^21003^USA
FT1|1|6|4|20071217094821||Credit|303756^Lipid Panel^L|||2|115

2) For reference laboratories or independent commercial labs, the billing department handles two types of billing: client and patient. Client billing is where the lab bills the services back to its client, the doctor’s office, clinic, etc. Patient billing involves third party billing based on patient coverage or direct bills to the patient. If the lab receives orders electronically via an HL7 interface, then the order message (ORM) may contain the needed billing information. Below is an example order for a serum Vitamin C test for a patient with a primary insurance carrier being Medicare:

IN1|1|UNK.|MR1|MEDICARE/COMMERICAL|P.O. BOX C32086^^RICHMOND^VA^23261||-0000000000|499032980||||00001231|00001231||MC|O
DONNELL^RICHARD^W^^|1|-19221027|7982 WELLINGTON DR^^WARRENTON^VA^22186^USA||||||||||||N||||-|499032980-A|||||||M||
OBR|1|L2435^LAB|010700^VITAMIN C (ASCORBIC ACID), SERUM^L||||20071002122600||||N||SICK|||23462^ALVAN^^^||||REQ#5468|||||||1^^^^^R|

3) Finally, an independent imaging center takes on the task of billing the technical and professional components of its services. The professional reads they do for hospitals or referring physicians require the patient’s billing information and the final reports for coding. The patient information can be sent via paper (e.g., faxing), sent electronically through an HL7 interface (ADT, BAR, or DFT messages), or sent via a file batch with a proprietary format. The reports used for coding can be transmitted using HL7 ORU messages.

An example BAR message that creates a new account with needed billing information follows:

GT1|0||JONES^ANN^M||756 E FANNIN ST^^LAGRANGE^TX^789450000|9799660489|||||M|||||CARE INN|457 NMAIN^^LAGRANGE^TX^78945|

For additional information, watch a 15-minute web seminar on the role HL7 messages play in different healthcare billing environments.

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Sonal N. Patel, MBA, BS, MT(ASCP) has extensive experience working in healthcare from both the provider and vendor perspective. Prior to Corepoint Health, she served as a Medical Technologist and Laboratory Supervisor at Roche Diagnostic/Golden Triangle Regional Medical Center/Baptist Memorial Hospital and also operated in several client services, support and training roles at Antrim/Sunquest/Misys Healthcare Systems.

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