EDI Process Flow At Veterans Health Administration (VHA) EDI Process Flow above flowchart represents the path that electronic claims follow at Veterans Health Administration (VHA). The objective of electronic billing is to submit completely correct claims. Claims sent electronically reach the payer faster, are processed faster, and are paid faster than claims submitted to the … Read More →
Clean Claim Requirements (Cigna vendors) Clean Claim Requirements were developed with the goal to process all claims at initial submission. Before Cigna can process a claim, it must be a “clean” or complete claim submission, which includes the following information, when applicable: primary carrier explanation of benefits (EOB) when Cigna is the secondary payer prescription for physical … Read More →
Prevea360 ASC X12 Acknowledgments And Additional Reporting Prevea360 will produce a Response Acknowledgement TA1 and Implementation Acknowledgement 999 for every 834 file received. Both of these are placed within the sponsor/trading partners /999 FTP folder for transaction acceptance review. The TA1 Response Acknowledgement will indicate that the file was successfully received as well as indicate what … Read More →
Functional Grouping and Transaction Set File Structure Options (Prevea360 Partner Guidelines) Prevea360 is able to process different variations of transaction sets. Option 1 is the most commonly received structure and is acceptable for files with up to 8000 members. Option 1 (All INS in one ST/SE) Due to system limitations, Prevea360 is unable to process files … Read More →
EDI Security-Related Requirements for A/B MACs and CEDI Arrangements With Clearinghouses and Billing Services (Part 1) A billing service is an entity that markets claim preparation services to providers and should also be able to perform related transactions for providers, such as eligibility and claim status inquiries. The billing service collects a provider’s claim information and … Read More →
HIPAA Security Requirements For Medicare Trading Partners A/B MACs, DME MACs, CEDI, and other entities contracting directly with CMS are considered service providers to CMS. As such, these entities are part of CMS’ system security boundary and must be in compliance with the Federal Information Security Management Act (FISMA) and are subject to CMS security … Read More →
HIPAA Transaction Standards as Designated by CMS HIPAA transaction standards shall be supported by the A/B MACs, DME MACs, CEDI or other contractors if designated by CMS for the electronic data with Medicare providers/submitters/receivers/COB trading partners. ASC X12 Technical Report 3s (TR3s) for mandated HIPAA transactions may be purchased from the official Washington Publishing Company … Read More →
Medicare EDI Enrollment Information Required EDI Enrollment Information Required for Inclusion at a Minimum in Each A/B MAC, and CEDI EDI Enrollment Form. Medicaid state agencies are not required to complete an EDI Enrollment Form as a condition for receipt of COB claims. In accord with a particular MAC’s business processes, providers who have a signed EDI … Read More →
Maintenance of Existing EDI Enrollments The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary’s Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business … Read More →
Electronic Remittance Advice (ERA) Enrollment Form The Medicare Electronic Remittance Advice (ERA) Enrollment process provides for collection of the information needed to successfully receive ERA transactions from Medicare and EDI trading partners. This agreement must be executed by each provider that receives ERA either directly to or from Medicare or through a third party. Each … Read More →