EDI Connectivity Requirements: Process Flows And Transmission Procedures (WPS Health Solutions)
EDI Connectivity ensures the integrity of the electronic transaction process. EDI Connectivity and the Trading Partner Agreement are related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. Trading Partners who wish to do business with WPS Health Solutions and its contracts electronically will be required to register their corporation/business, and any subsequent Submitter IDs for that corporation.
Process Flows Guidelines:
- A claim is sent to WPS by a submitter
- The claim goes through the initial edits. If it fails the initial edits, then WPS creates the failed message. If it passes the initial edits, then it is sent to the Custom Off The Shelf Translator (COTS)
- At the COTS translator, the claim can either be accepted, be accepted with errors, or reject
- The COTS will produce the 999, which will be sent to the provider to advise whether the claim was accepted and sent for further processing or rejected
- If a claim rejected, it goes no further
- If a claim is accepted or accepted with errors, then it is sent to the Common Edit Module (CEM)
- At the CEM, the claim can be accepted and passed into adjudication system or be rejected
- Date editing on all inbound transactions will be done based on the WPS Health Solutions local time, e.g. Central Standard Time.
- The CEM will produce the Claim Acknowledgment (277CA), which will be sent to the submitter to advise whether the claim was accepted adjudication system or rejected
- Once the claim has been processed in adjudication system and the remittance (either Standard Paper Remittance (SPR) or Electronic Remittance Advice (835) is produced.
WPS Health Solutions does have provisions or procedures for technical Internet connectivity specifications for real time processing of these transactions: 276/277, 837, or 835.