Sending Electronic Claims

Basic Guides For Sending Electronic Claims To SummaCare

SummaCare accepts all ASCX12 compliant transactions, the HIPAA Implementation Guides allow for some discretion in applying the regulations to existing business practices. Understanding SummaCare business practices may expedite claims processing for trading partners as they exchange EDI transactions with SummaCare.

Electronics submission of claims will follow these guidelines:

  • Claims currently filed on CMS-1500 format will be sent as an 837P.
  • Claims currently filed on ADA format will be sent as an 837D.
  • Claims currently filed on UB-92 format will be sent as an 837I.

All Trading Partners (Entities submitting claim files directly to SummaCare) must complete the EDI registration process before sending any transactions to SummaCare. This process is detailed separately in the Communication Companion Guide and on the SummaCare Website.

Furthermore, all providers are required to file a change in registration with SummaCare when the following situations occur:

  • Changes in Clearinghouse, Billing Service, Software Vendor or any Vendor handling the provider’s
    electronic data information.
  • Change in address.
  • Change or addition of your Tax Identification Number (TIN).
  • Change in name.

NPI Implementation

SummaCare will reject claims that do not contain a NPI(at the Billing, Paid To or Rendering level). The lone exception for this will be provider submitting a claim with a valid taxonomy exception. SummaCare will reject a claim containing an invalid NPI number based on check digit validation.

Testing Prior to Production

All Trading Partners must complete transaction testing prior to submission of transactions in production. Prior to submitting production claims electronically, all providers or their designated vendor must complete successful transaction testing. Providers must maintain a successful level of transaction
submission to remain in production.

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

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