HIPPA-Privacy-Rules

Electronic Medical Claims Transmission Requirements (CGS Medicare)

EDI gives you the ability to transmit Electronic Media Claims (EMC) to Medicare in a Health Insurance Portability and Accountability Act (HIPAA) compliant format. Electronic Data Interchange (EDI) will simplify time-consuming, labor-intensive jobs and ultimately enable you to increase your productivity.

The following are a few of the benefits experienced by utilizing the EDI options offered by Medicare:

  • Faster payments: the payment floor for electronic claims is shorter than that of paper claims
  • Ease of billing electronically (support is available)
  • More efficient and accurate claims filing; data is received precisely as input by your office, eliminating the chance of processing errors
  • Electronic front-end edit reports: confirmation can be downloaded via modem within 48 hours of transmission. This report verifies the acceptance of claims and Certificates of Medical Necessity (CMNs) & DME Information Forms (DIFs).
  • Online or batch versions of Claim Status Inquiry (CSI)
  • Availability of Electronic Remittance Advice (ERAs) for faster payment posting Lower administrative, postage, and handling costs
  • Ability to submit claims and CMNs/DIFs seven days a week, including holidays.

Section 3 of the Administrative Simplification Compliance Act (ASCA), Public Law (PL) 107-105, and the implementing regulation at 42 CFR 424.32 require that all initial claims for reimbursement under Medicare (except from small providers) be submitted electronically as of October 16, 2003, with limited exceptions.

Initial claims are those claims submitted to a MAC for the first time, including:

  • Resubmitted previously rejected claims
  • Claims with paper attachments
  • Demand claims
  • Claims where Medicare is secondary and there is only one primary payer
  • Nonpayment claims Medicare will not cover claims submitted on paper unless they meet the limited exception criteria. Claims denied for this reason will contain claim adjustment reason code 96 (Noncovered charge[s]) and remark code M117 (Not covered unless submitted via electronic claim).

To learn more about EDI in Healthcare and become a CEDIAP® (Certified EDI Academy Professional), please visit our course schedule page.

Leave a Reply

Your email address will not be published.

Post Navigation