Authorization EDI Data Submission Requirements (IEHP Providers)
Authorization EDI Data policy applies to IPAs and other Entities that have been delegated medical management where IEHP retains financial risk or administrative processing for those services. IEHP contractually requires Independent Provider Associations (IPAs) to submit all authorization data to IEHP at a minimum frequency of once per business day and within one (1) business day of the Authorization being finalized. All submitters must meet timeliness, validity, and adequacy requirements for all authorization data submissions to IEHP. IEHP requires submitters to adhere to IEHP’s authorization file format when submitting authorization data. Mutually agreed-upon modifications may be made to this format on a case-by-case basis at the discretion of IEHP.
IPAs are required to submit this data for the following reasons:
- To enable IEHP to perform the administrative duties of processing claims.
- To ensure that non-PCP services have been properly authorized and are medically necessary and appropriate.
Providers must submit, via Secure File Transfer Protocol (SFTP), the appropriate EDI authorization information in the IEHP’s authorization file format at a minimum of daily and within one (1) business day of an authorization being finalized. Providers must submit data for each service requested for a Member that requires an authorization request.
Monthly aggregate authorization file data must meet the following requirements:
- Timeliness: 75% of authorization data must be received by IEHP within one (1) business day of the authorization being finalized (i.e.: approved or denied) as indicated by the status date in the file format specifications. 100% of authorization data must be received by IEHP within two (2) business days of the authorization being finalized (i.e.: approved or denied) as indicated by the status date in the file format specifications. Authorization data must be transmitted at a minimum of daily during normal business hours unless there is no authorization data to transmit.
- Validity: The structure of the authorization format must adhere to IEHP’s authorization file format or a mutually agreed upon format.
- Adequacy: 100% of all authorization data must be transmitted to IEHP.