EDI Claims Procedures And Guidelines For Billing Parties

EDI ClaimsEDI Claims procedures state that providers are encouraged to submit clean claims and encounter data electronically. Buckeye Health Plan Medicare Advantage can receive an ANSI X12N 837 professional, institution, or encounter transaction. In addition, Buckeye Health Plan can generate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP) and deliver it securely to providers electronically or in paper format, dependent on provider preference.

Providers who bill electronically are responsible for filing claims within the same filing deadlines as providers filing paper claims. Providers who bill electronically must monitor their error reports and evidence of payments to ensure all submitted claims and encounters appear on the reports. Providers are responsible for correcting any errors and resubmitting the affiliated claims and encounters. Buckeye Health Plan Medicare Advantage has the ability to receive coordination of benefits (COB or secondary) claims electronically. Advantage follows the 5010 X12 HIPAA Companion Guides for requirements on submission of COB data.

All providers who have rendered services for Buckeye Health Plan Medicare Advantage members can follow EDI Claims procedures and file claims. It is important that providers ensure Buckeye Health Plan Medicare Advantage has accurate and complete information on file. Please confirm with the Provider Services department or your dedicated Provider Relations Specialist that the following information is current in Buckeye Health Plan files:

  • Provider Name (as noted on current W-9 form)
  • National Provider Identifier (NPI)
  • Group National Provider Identifier (NPI) (if applicable)
  • Tax Identification Number (TIN)
  • Taxonomy code (This is a REQUIRED field when submitting a claim)
  • Physical location address (as noted on current W-9 form)
  • Billing name and address (as noted on current W-9 form).

Buckeye Health Plan recommends that providers notify Buckeye Health Plan Medicare Advantage 60 days in advance of changes pertaining to billing information. If the billing information change affects the address to which the end of the year 1099 IRS form will be mailed, a new W-9 form will be required. Changes to a provider’s TIN and/or address are NOT acceptable when conveyed via a claim form.

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