Insurance Company EDI Set-up

Insurance Company EDI Set-up At Veterans Health Administration

Improper insurance company EDI Set-up and/or provider IDs within VistA can cause claims rejection. With EDI Billing, there are fields in an 837 claim transmission that are autopopulated with the data defined in VistA. This information must be accurate to generate a clean electronic claim.

  1. Activate New Payer to Transmit eClaims. The typical business process for setting up new payers is:
    • The Insurance Verification Office initially enters a new payer into VistA.
    • Lists of new payers are printed and provided to the medical center’s billing office on a regular basis (daily/weekly). Some individuals become members of the IB New Insurance mail group so they receive e-mail bulletins whenever a new insurance policy is added to VistA.
    • Billing staff uses the Insurance Company Editor to define Provider IDs: Type of Coverage, Electronic Insurance Type and Electronic Transmit? by Insurance Company. The Profession/Institutional Payer Primary and Secondary IDs are also defined using the Insurance Company Editor.
    • Billing staff use The Insurance Company Editor to specify the correct Electronic Plan Type for each Insurance Plan.
  2. Define EDI settings for a Blue Cross/Blue (BC/BS) Shield Insurance Company
  3. Define EDI settings for a Blue Cross/Blue Shield Group Insurance Plan
  4. Activate Existing Commercial Payer to Transmit eClaims. To activate an existing payer to receive electronic claims, use the Billing Parameters screen in the Insurance Company Editor. The EDI – Transmit? field on this screen must be set to YES-LIVE. In the Live mode, bills are automatically sent electronically and cannot be printed until the confirmation of a receipt message has been received from the FSC.
  5. Activate Existing Payer to Test Primary Blue Cross/Blue Shield eClaims Blue Cross and Blue Shield payers require the submission of test claims before accepting live claims. A member of the eBilling Team contacts someone at the facility to coordinate this testing.

If an eBilling Team member, request claims submitted electronically as a Live test enables the BC/BS payer to receive primary claims electronically but in a testing mode, use the Billing Parameters screen in the Insurance Company Editor. The EDI -Transmit? field on this screen must be set to YES-TEST. In testing mode, bills are automatically sent electronically and cannot be printed until the confirmation of receipt message has been received from the FSC.

To learn more about EDI and become a certified  EDI Professional please visit our course schedule page.

Leave a Reply

Your email address will not be published.

Post Navigation