Claims EDI Processing

Claims EDI Processing (IEHP Providers EDI)

Claims EDI Processing Submission helps to speed processing and ensure accuracy and security. While direct submission of claims is allowed, this option is more practical for large Provider groups and facilities. Many Providers and billers may find that a more realistic method is to utilize a claims clearinghouse.

Claims data contains private healthcare information; therefore, it must comply with HIPAA regulations. For electronic claims, data exchanged by IEHP must comply with the ANSI ASC X12 standards as well as the IEHP companion guide. For purposes of claims data interchange, these standards apply to claims data, claim receipt, claim status acknowledgements, and claims payment remittances. The standards also dictate data requirements and the appropriate file formats.

Whether a Provider, facility, or third party, claims can be directly submitted to IEHP for purposes of payment. There are several steps that must be completed in order to be approved:

  1. Submitter Enrollment
    • Enrollment Form Completion
    • Contract, Trading Partner Agreement, or Business Associates Agreement with IEHP.
    • Submitter ID/Submitter SFTP account assignment
  2. EDI Testing
    • SFTP connection testing
    • X12 implementation guide file format validity testing for all relevant file types
    • IEHP companion guide validity testing for all relevant file types
    • Clean claim data validity
  3. Submitter Certification for each relevant file type
    • Provisional approval at sccessful conclusion of all testing
    • Written (Email attachment) notification of Submitter approval
    • File Size Limitation
    • Institutional and Professional is limited to 5K per file.

Claim file/s Manifest Report. IEHP requires a daily manifest report in order to reconcile the submissions from the trading partner to the files received and processed by IEHP.

Manifest. The Naming Conventions for Manifest EDI Claim submissions consists of the following:

  • All file names start with the Provider’s 3 digit Submitter ID number.
  • The 4th, 5th character is ‘MF’ for Manifest report.
  • The 6th through 11th characters for the date the Manifest file was created (MMDDYY).
  • The extension must be MF.PGP to identify the Manifest submitted by the Clearinghouse/Trading Partner.

After all steps are completed, the submitter is eligible to directly submit electronic claims to IEHP.

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