SelectHealth EDI Claims

SelectHealth EDI Claims Submission – Basic Transactions

SelectHealth EDI Claims can be sent electronically through an Electronic Data Interchange (EDI) instead of submitting claims by mail. Claims submitted electronically are typically more accurate and allow to reimburse more quickly. EDI is more than just claims, however. Through EDI transactions, you can also receive remittance advice, eligibility, and claim status information. The SelectHealth EDI supports the following EDI transactions:

Healthcare Claim (837)
The 837 is the transaction for submitting claims electronically. It allows for faster claims adjudication and payment. Accuracy is also increased because the claim information that is received is loaded directly into system. SelectHealth can also receive coordination of benefits (COB) claims and corrected bills electronically. The 837 can result in the following responses: the Functional Acknowledgement and the Healthcare Claims Acknowledgement.

Functional Acknowledgement (997/999)
This acknowledgement provides information regarding the syntactical and implementation guide quality of an electronic claims submission (837). It contains information on submitted claims such as accepted/rejected statuses and reasons for rejections, if applicable. Claims may reject at this level if there are invalid characters or missing information. A rejected claim will not progress; it requires correction of the inaccurate data and resubmission to be considered. SelectHealth does not reject entire batches of claims unless every claim in that batch has an error.

Healthcare Claim Acknowledgement (277FE)
For all claims accepted in the 997, this transaction provides information regarding the accept/reject statuses of claims based on the internal requirements. As with the Functional Acknowledgement, if a claim rejects on the Healthcare Claim Acknowledgement, it requires correction of the inaccurate data and resubmission to be considered.

Healthcare Claim Payment/Advice (835)
Like the paper remittance advice, the electronic remittance advice details payment information on claims. However, the ERA allows payments to auto post and is faster and more efficient than waiting for a paper remittance advice.

Eligibility Benefit Enquiry and Response (270/271)
This transaction allows for the verification of a member’s eligibility and benefit information without the inconvenience of a call. The 271 response will contain information such as eligibility, eligibility dates, copay, coinsurance, deductible, out of pocket, visit limits, and benefit limits.

Claim Status Request and Response (276/277)
This transaction allows for the verification of the status of a specific claim that has been submitted. Information included in the 277 will be the current status of the claim, whether the claims has been received, pended, or finalized, as well as when the claim entered that status. A finalized claim status response will also include any paid amounts and payment information such as check number.

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