Medical EDI

Medical EDI Implementation Guide (Electronic Medical Report Submission) Medical EDI is the electronic submission of medical bills by all healthcare providers. The Medical EDI Team assists electronic medical submitters with the management of electronic medical filings. To allow comparison benchmarking among the insurance industry, the team generates monthly report cards that denote the primary reasons for Read More →

HIPAA Compliant 837 Claim

HIPAA Compliant 837 Claim Audit (SummaCare) When the HIPAA Compliant 837 claims file is submitted it is checked for ASC X12 syntax and HIPAA compliance errors. When the compliance check is complete, a 997 Acknowledgement will be sent to the trading partner informing them if the file has been accepted or rejected. If multiple transaction sets (ST-SE) are Read More →

837 Institutional Health Care Claim

837 Institutional Health Care Claim Mapping Guidelines (SummaCare) After the claim transmissions have passed Implementation Guide compliance checks for acceptance into the SummaCare system, business edits, specific to SummaCare, are then applied to the incoming HIPAA compliant claims. The business edits include security validation and the verification of proprietary business requirements. Guidelines are used in conjunction with the ASC X12N Read More →

Facilities in a Health System

Facilities in a Health System: SummaCare Explained If you are a facility in a Health System and your checks are issued to the Parent Company, you should use the NPI number specifically assigned to your facility. If you use another facility’s NPI number under the Parent Company, it will result in the check being issued correctly to the Read More →

EDI Claims Processing

EDI Claims Processing Guidelines (SummaCare) Any claim submitted that contains more than 85 service lines will be split into two claims by SummaCare for payment. When submitting an 837 transaction for members after billing their other insurance sources, the other payer’s adjudication details that were provided on the 835 Remittance transaction must be supplied to SummaCare. The Read More →

Sending Electronic Claims

Basic Guides For Sending Electronic Claims To SummaCare SummaCare accepts all ASCX12 compliant transactions, the HIPAA Implementation Guides allow for some discretion in applying the regulations to existing business practices. Understanding SummaCare business practices may expedite claims processing for trading partners as they exchange EDI transactions with SummaCare. Electronics submission of claims will follow these guidelines: Claims currently filed Read More →

Claims Returned

Claims Returned Within The 835 HIPAA Transaction (Summa Care) Notes that are important to claims processing are as follows: 835 Transactions are only generated for claims that have a “paid” or “denied” status. Claims still in the adjudication process or returned with an error messages do not receive an 835 response. If a provider submits Read More →

HIPAA training

Summa Care 835 Health Care Claim Payment Advice: Implementation Guides In order to receive an 835 Health Care Claim Payment Advice, submitters of health care claims must complete the following: Complete and submit a Trading Partner Agreement to SummaCare or enter into a contractual agreement with a SummaCare contracted Trading Partner. Complete the SummaCare 835 Read More →

834 Eligibility Enrollment

834 Eligibility Enrollment and Maintenance FAQs (Summa Care) 834 Eligibility Enrollment and Maintenance files, sent to Summa Care, will potentially be checked for HIPAA compliance. Vendors should validate that the file being submitted is HIPAA-compliant prior to submitting the file for testing or production. Find some frequently asked questions below. Can a group be terminated by using Read More →

HIPAA EDI

Summa Care 834 Eligibility Enrollment and Maintenance Example All Trading Partners must complete transaction testing prior to submission of transactions in production. Prior to submitting production enrollment information electronically, all sponsors or their designated vendor must complete successful transaction testing. Sponsors must maintain a successful level of transaction submission to remain in production. There should Read More →