Repricing Overview

Claim pricing is the process by which specific data elements submitted on Professional and Institutional claim forms (CMS-1500 or UB-04) are entered into a database for the purpose of calculating the negotiated amount to be reimbursed to the billing provider under the terms of their contract.

The method by which medical claims data are entered into the First Choice Health PPO Network (FCH PPO) database consists of the following:

• EDI (electronic data interchange)

  Electronic claim files that are received through an EDI vendor or direct client electronic submission partnership and "auto-priced" in the FCH PPO system.

• Paper Claim Scanning

  Process by which paper claims received by FCH PPO are scanned to create an image file that is converted to an EDI 837 HIPAA compliant claim file that can be "auto-priced" in the FCH PPO system.

• Paper Claim Pricing

  While most paper claims are scanned for conversion to an electronic format, there are certain types of claims that cannot be effectively converted to an EDI claim. This type of claim will undergo the process of manual data entry for claim pricing.