CMS EDICMS EDI Enforcement Notes and Guidelines for Emdeon Partners

CMS EDI Enforcement guidelines described below refer to payers who continue to operate under contingency plans under the Centers for Medicare and Medicaid Services (CMS). Such payers may accept CMS EDI claims transactions in a HIPAA format but may not be prepared to accept or use all of the data content. Emdeon continues to work with both submitters and receivers of claim transactions to ensure that the EDI transactions continue to flow. Providers should begin to submit data content using the rules in the HIPAA Implementation Guides and CMS EDI. Emdeon will enforce X12 syntax rules for all claims going to receivers of the 837 transaction. Claims that fail to meet the syntax requirements will be rejected and must be corrected and resubmitted by the submitter. Emdeon will not reject claims that do not contain all required data content unless instructed to do so by trading partners.

Available Emdeon Defaults (Optional)

Upon request of the receivers, Emdeon will provide default values. Use of such default values will enable receivers with translators or other adjudication software that might otherwise reject claims to accept transactions that may not have all of the data required by the Implementation Guides but have the proper data required for adjudication.

Emdeon will generally create the methodology used to determine when to create segments and loops with defaulted data according to the following rules:

  • If partial data exists within a loop or segment but other required data is missing, Emdeon will default the required data elements within that segment or loop as listed in the Companion Guide. For example, when the provider identifiers are received without a name, Emdeon will default ‘XX’ in the provider’s name in order to forward the identifier on to the receiver. If no default value is listed in the Companion Guide, Emdeon will not default data for that element.
  • Emdeon will not create a situational loop that contains all defaulted data. Situational Loops will only be created when at least one data element is sent by the claim submitter.

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