Medical EDI Implementation Guide (Electronic Medical Report Submission)
Medical EDI is the electronic submission of medical bills by all healthcare providers. The Medical EDI Team assists electronic medical submitters with the management of electronic medical filings. To allow comparison benchmarking among the insurance industry, the team generates monthly report cards that denote the primary reasons for initial medical bill rejections. The guides below refer to the rules set by Florida Department of Financial Services, Division of Workers’ Compensation.
Sender must complete and submit the Sender Specifications document to the Division and receive the assignment of a Sender ID prior to submitting electronic transmissions. A Sender must provide the Division with an accurate and complete list of Insurers and Service Companies/Third Party Administrators (TPA) for whom they will be transmitting electronic data. This list must include the Insurer Name, Insurer Code Number, Insurer FEIN and the Claim Administrator Name, Service Company/Third Party Administrator (TPA) Code Number, Claim Administrator FEIN and the Claim Administrator physical office location postal code.
It is the responsibility of the Sender to notify the Division when any insurer or claim administrator is added to or deleted from the client list, to avoid medical bill rejection when transmissions are processed. The Sender Client Listing document is used for this notification. An SSH (SFTP) account shall be established for transmitting electronic medical transactions.
The Sender will be notified via email if a data transmission cannot be processed, and the transmission will be placed in the “badfiles” folder in the Sender’s SSH (SFTP) account. Data are not considered “filed with the Division” until the Sender submits a replacement transaction that is successfully accepted by the Division.
Processing of Medical Data Transmissions
Each data transmission received is processed through a data quality program specific to the medical bill record type. Each medical bill is validated and analyzed. Once the transmission has been processed through the data quality programs, Medical Bill Acknowledgements are generated. These reports will be placed in the outgoing folder on the Division’s SSH (SFTP) account for the Sender to retrieve as notification of the Division’s acceptance or rejection of the medical report data submitted.
To learn more about medical EDI billing and become a certified EDI Professional please visit our course schedule page.