EDI Testing Requirements (Trading Partners)
EDI Testing – WPS Health Solutions follows CMS testing requirements. Main requirements are the following:
- 25 claim minimum
- ISA14 Strongly encourage to use a 1 or a TA1 will not generate
- ISA15 must = T for testing
- 100% Syntax
- 95% Medicare business rules
- Submitter is considered in test until approved by contractor.
During EDI testing all claim submitters must produce accurate electronic test claims before being allowed to submit claim transactions in production. All submitters must send a test file containing at least 25 claims, which are representative of their practice or services. The number of claims could be increased or decreased, on a case by case basis, to ensure adequate testing of any given submitter. Test claims are subject to standard syntax and IG semantic data edits; documentation will be provided when this process detects errors.
Standard syntax testing validates the programming of the incoming file and includes file layout, record sequencing, balancing, alphanumeric/numeric/date file conventions, field values, and relational edits. Test files must pass 100 percent of the standard syntax edits before production is approved.
IG Semantic Data testing validates data required for claims processing, e.g., procedure/diagnosis codes, modifiers. A submitter must demonstrate, at a minimum, a 95 percent accuracy rate in data testing before production is approved where, in the judgment of WPS Health Solutions, the vendor/submitter will make the necessary correction(s) prior to submitting a production file. ForFIs, the minimum 95 percent accuracy rate includes the front-end edits applied using the FISS implementation guide editing module.
Test results will be provided to the submitter within three (3) business days; during HIPAA version transitions this time period may be extended, not to exceed ten (10) business days. Many claim submitters use the same software, or the same clearinghouse to submit their electronic claims to Medicare. Vendors and clearinghouses are expected to test by line of business and contract. Vendors and clearinghouses may also contact WPS Health Solutions to receive blanket approval.
Providers/suppliers who submit transactions directly to more than one FI, Carrier, RHHI, A/B MAC, and/or CEDI, and billing services and clearinghouses that submit transactions to more than one FI, Carrier, RHHI, A/B MAC, and/or CEDI, must contact each FI, Carrier, RHHI, A/B MAC, and/or CEDI with whom they exchange EDI transactions to inquire about the need for supplemental testing whenever they plan to begin to use an additional EDI transaction, different or significantly modified software for submission of a previously used EDI transaction, or before a billing agent or clearinghouse begins to submit transactions on behalf of an additional provider.
The individual FI, Carrier, RHHI, A/B MAC, and/or CEDI may need to retest at that time to re-establish compatibility and accuracy, particularly if there will also be a change in the telecommunication connection to be used. Billing services and clearinghouses are not permitted to begin to submit or receive EDI transactions on behalf of a provider prior to submission of written authorization by the provider that the billing agent or clearinghouse has been authorized to handle those transactions on the provider’s behalf.