Electronic Claim Flow Description
In order to send claims electronically to Louisiana Healthcare Connections, all EDI claims must first be forwarded to one of Louisiana Healthcare Connections’ clearinghouses. This can be completed via a direct submission to a clearinghouse or through another EDI clearinghouse. Once the clearinghouse receives the transmitted claims, they are validated against their proprietary specifications and plan specific requirements. Claims not meeting the requirements are immediately rejected and sent back to the sender via a clearinghouse error report. It is very important to review this error report daily to identify any claims that were not transmitted to Louisiana Healthcare Connections.
The name of this report can vary based upon the provider’s contract with their intermediate EDI clearinghouse. Accepted claims are passed to Louisiana Healthcare Connections, and the clearinghouse returns an acceptance report to the sender immediately.
Claims forwarded to Louisiana Healthcare Connections by a clearinghouse are validated against provider and member eligibility records. Claims that do not meet provider and/or member eligibility requirements are rejected and sent back on a daily basis to the clearinghouse. The clearinghouse in turn forwards the rejection back to its trading partner (the intermediate EDI clearinghouse or provider).
It is very important to review this report daily. The report shows rejected claims and these claims need to be reviewed and corrected timely.
Claims passing eligibility requirements are then passed to the claim processing queues. Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from the clearinghouse must be reviewed and validated against transmittal records daily. Since the clearinghouse returns acceptance reports directly to the sender, submitted claims not accepted by the clearinghouse are not transmitted to Louisiana Healthcare Connections. Rejected electronic claims may be resubmitted electronically once the error has been corrected. Be sure to clearly mark your claim as a corrected claim per the instructions above.
To learn more about EDI and become a certified EDI Professional, please visit our course schedule page.