Submitting HIPAA EDI Transactions

Submitting HIPAA EDI Transactions – Basic Procedures

Submitting HIPAA EDI Transactions rules below are available for providers and their vendors who are interested in submitting HIPAA EDI transactions to HMSA for electronic claims submission, claims status, eligibility and referrals/pre-authorizations. The Electronic Trading Partner Agreement (TPA) must be signed and returned to HMSA before transactions can be submitted. The TPA includes a Business Associate Authorization Form (BAAF) for Providers to designate Business Associates acting on their behalf (e.g., vendors, clearinghouses).

Approval Process

HMSA reserves the right to exercise prior approval of EDI submission arrangements from any source. There are two parts to this approval process. The first part relates to the technical details of the data processing arrangement. The second part relates to the specific provider whose transactions are submitted. It will be necessary for HMSA to review and approve each provider and for each approved provider to sign an Electronic Trading Partner Agreement. HMSA reserves the right to revoke approval for a provider, group of providers, or organization performing data processing support.

By automating the claims submission process, the provider should realize a faster turnaround time since it will eliminate the need for HMSA to process the majority of the claims manually. However, the length of time required to process a claim also depends on many other variables.

Please note that for all HMSA claims, the provider should verify the patients’ data file with current identification information from each encounter, since claims with invalid membership numbers will not be accepted for electronic processing. Providers should establish a procedure to contact those patients to obtain information so their health plan information can be updated.

Testing Procedures

After an agreement has been reached between the provider and HMSA regarding EDI claims submission, a testing period may be necessary. The purpose of testing is to ensure that the data from the provider’s data processing system meets all technical requirements, and to work out the data transfer procedures. Depending on the quality of the test data and/or any problems that arise, additional tests may be requested. Frequent coordination between the provider and HMSA will be necessary during this period to ensure rapid resolution of problems. At the successful conclusion of testing the regularly scheduled input of EDI claims will begin

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