EDI Contracting Between Electronic Vendors and Passport Health Plan
EDI Contracting is possible for providers interested in submitting claims electronically to the Plan. Providers can contact the EDI Technical Support Group to obtain names of other EDI clearinghouses and vendors for succesful EDI Contracting.
After the registration process is completed and you have received all of your certification material, proceed as follows:
- Read the instructions within the Provider Manual, Section 18.2 carefully with special attention to the information on exclusions, limitations, and especially, the rejection notification reports.
- Contact your system vendor and/or Emdeon to inform them you wish to initiate electronic submission to the Plan.
- Be prepared to inform the vendor of the Plan’s electronic payer identification number. The Plan’s number is 61129.
EDI Contracting Specific Data Guides
Claims transmitted electronically must contain all the same data elements identified within the “Claim Filing” section of Passport Health Plan’s Provider Manual. Emdeon or any other EDI clearinghouse or vendor may require additional data record requirements.
EDI Contracting Claim Flow Description
To be sent electronically to the Plan, all EDI claims must first be forwarded to Emdeon. This can be completed via a direct submission or through another EDI clearinghouse or vendor.
Once Emdeon receives the transmitted claims, they validate the claims against Emdeon’s proprietary specifications and Plan specific requirements. Claims not meeting the requirements are immediately rejected and sent back to the sender via a Emdeon error report. The name of this report can vary based upon the provider’s contract with its intermediate EDI vendor or Emdeon.
Accepted claims are passed to the Plan, and Emdeon returns an acceptance report to the sender immediately. Claims forwarded to the Plan by Emdeon are immediately validated for provider identification number requirements. Claims that do not meet this requirement are rejected and sent back to Emdeon, who also forwards this rejection to its trading partner – the intermediate EDI vendor or provider.
Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from Emdeon or other contracted vendors must be reviewed and validated against transmittal records daily.
Emdeon will only send a functional acknowledgement to its trading partner whether it is the EDI vendor or provider. Providers using clearinghouses and vendors other than Emdeon are responsible for arranging to have these reports forwarded to the appropriate billing or open receivable departments.
Claims containing valid provider identification numbers are also validated against member eligibility records before acceptance by the Plan. If a patient cannot be identified as a member of the Plan, a denial letter will be forwarded directly to the provider. This letter is sent to the payment address documented in the Plan’s provider file. Claims passing eligibility requirements are then passed to the claim processing queues. Claims are not considered as received under timely filing guidelines if rejected for missing or invalid member data.