EDI For Medicare

EDI For Medicare Fee For Services (FFS) Introduction And Requirements

EDI For Medicare FFS is not limited to the submission and processing of claim related transactions, but includes processes such as provider EDI enrollment, beneficiary eligibility, coordination of benefits, as well as security and privacy concerns. So as not to be duplicative, where EDI is a relevant part of a Medicare business process, it will be indicated here, however, the specifics of the business process will be maintained in its respective IOM chapter or comparable communication venue.

For a provider, business associate, or other trading partner to engage in EDI for Medicare FFS, it must first establish an EDI agreement with Medicare. There are two ways to do this: 1) complete and submit paper CMS Form 855, or 2) submit an Internet based application via the Provider Enrollment, Chain and Ownership System (PECOS) system.

In order to implement the HIPAA administrative simplification provisions, specific ASC X12 and NCPDP transactions have been named under part 162 of title 45 of the Code of Federal Regulations as electronic data interchange (EDI) standards for Health Care. All other EDI formats for health care became obsolete on October 16, 2003. The Final Rule for Health Insurance Reform: Modifications to the Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Standards

Medicare FFS therefore incorporates by reference any errata documents by the original mandated regulation compliance date through the Federal Register notice(s). Moving forward, all newly adopted errata documents are to be accepted and integrated as part of the EDI transaction(s). Medicare FFS further adopts the Accredited Standards Committee (ASC) X12 and National Council for Prescription Drug Programs (NCPDP) transaction standards as part of its EDI Acknowledgment Model.

Medicare FFS is utilizing the following EDI transactions:

  • ASC X12 Health Care Eligibility Benefit Inquiry and Response (270/271)
  • ASC X12 Health Care Claim:
    • Professional (837)
    • Institutional (837)
  • ASC X12 Interchange Acknowledgment, TA1(not required under HIPAA)
  • ASC X12-Implementation Acknowledgment For Health Care Insurance (999) (not required under HIPAA)
  • ASC X12 Health Care Claim Payment/Advice (835)
  • ASC X12 Health Care Claim Status Request and Response (276/277)
  • ASC X12 276/277 claim status
  • ASC X12 Health Care Claim Acknowledgment (277) (not required under HIPAA)
  • Telecommunication Standard, National Council for Prescription Drug Programs D.0
  • Batch Standard, National Council for Prescription Drug Programs.

Leave a Reply

Your email address will not be published.

Post Navigation