Medicare EDI

Medicare EDI Service Overview And Advantages

Medicare EDI (Electronic Data Interchange) is the computer-to-computer electronic exchange of business documents using standard format. Medicare EDI gives you the ability to transmit Electronic Media Claims (EMC) to Medicare in a Health Insurance Portability and Accountability Act (HIPAA) compliant format.

The acceptable HIPAA compliant format is the American National Standards Institute (ANSI) X12N Version 4010A1 837 transaction and the National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard.

Electronic Data Interchange (EDI) will simplify time-consuming, labor-intensive jobs and ultimately enable you to increase your productivity. The following are a few of the benefits experienced by utilizing the EDI options offered by Medicare:

  • Faster payments: the payment floor for electronic claims is shorter than that of paper claims
  • Ease of billing electronically (support is available)
  • More efficient and accurate claims filing; data is received precisely as input by your office, eliminating the chance of processing errors
  • Electronic front-end edit reports: confirmation can be downloaded via modem within 48 hours of transmission. This report verifies the acceptance of claims and Certificates of Medical Necessity (CMNs) & DME Information Forms (DIFs)
  • Online or batch versions of Claim Status Inquiry (CSI) and Beneficiary Eligibility (BE)
  • Availability of Electronic Remittance Advice (ERAs) for faster payment posting
  • Lower administrative, postage, and handling costs
  • Ability to submit claims and CMNs/DIFs seven days a week, including holidays.

Section 3 of the Administrative Simplification Compliance Act (ASCA), Public Law (PL) 107-105, and the implementing regulation at 42 CFR 424.32 require that all initial claims for reimbursement under Medicare (except from small providers) be submitted electronically. Initial claims are those claims submitted to a Medicare fee-for-service contractor, DME MAC, or fiscal intermediary for the first time, including:

  1. Resubmitted previously rejected claims
  2. Claims with paper attachments
  3. Demand claims
  4. Claims where Medicare is secondary and there is only one primary payer
  5. Nonpayment claims

Medicare will not cover claims submitted on paper unless they meet the limited exception criteria. Claims denied for this reason will contain claim adjustment reason code 96 (Noncovered charge[s]) and remark code M117 (Not covered unless submitted via electronic claim).

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