EDI Overview and Enrollment Procedures For Optima Health Providers
EDI overview and requirements are to be used with the HIPAA-AS Implementation Guide. Each EDI vendor will have to sign a Trading Partner Agreement, which includes the Network Access Agreement and the Business Associate Agreement.
EDI overview: Business Use
- Each transaction set will be used to expedite the execution of electronic information, and accelerate the processing and payment of a claim or encounter.
- The 837 transaction may be sent daily, with a disposition report available the next business day. The disposition report replaces the 997 Acknowledgement File.
- The 835 transaction file consists of a separate remittance file (ERA) and a separate electronic funds file (EFT).
- Vendors may elect to receive an EFT/ERA from Optima Health directly, as long as they can receive data files in the HIPAA compliant ANSI 835 format.
EDI overview: EFT Payment Schedule
The following information summarizes Optima Health’s general payment schedule. In cases where our offices are closed, such as holidays or extremely severe weather, the scheduled payments will be processed on the next business day. While we can not foresee every circumstance, our professionally trained staff will make every effort to adhere to the following payment schedule:
Weekly Payment Processing schedule:
- Monday – All commercial (fully insured), Medicare and Medicaid
- Tuesday – Optima Behavioral Health & Self-Funded employer groups
- Wednesday – Federal employee groups and Self-Funded employer groups
Payments processed monthly:
- Provider Capitation and Practice Management payments are processed on or before the 15th of every month.
- All remaining payment types not already listed will be processed on or before the 20th of each month.
- For providers who choose to receive their payments electronically, funds are normally deposited 24 hours after the payments are processed. Associated electronic remittance advice is usually transmitted 24 – 48 hours after payments are processed. All other providers will receive paper checks/remittances through the US postal system
Note 1: While claims payments are processed on these days, funds are not released until the payments are funded by their associated employer group. This applies to Self-Funded employer groups only.
Note 2: While Optima Health will make every effort to adhere to the payment schedule, the availability of funds is also dependent on the provider’s banking institution.
Once a Trading Partner Agreement is signed and the method of transferring files determined, test files may be submitted to Optima Health.
- Inbound transactions will be tested with Claredi to ensure transactions are valid and compliant.
- 837 claims must have valid Optima Health member ID numbers and Optima Health provider ID numbers.
- Optima Health will work with all trading partners to identify and eliminate errors.
- The Electronic Funds Transfer/Electronic Remittance Advice implementation timeline is dependent on the trading partners ability to test the receipt and distribution of the EFT/ERA data files.
- Testing is expected to take no more than 2 months to complete.
- Optima Health will notify trading partner that transaction testing is complete and schedule a mutually agreed upon date to move the transaction to production.