Eligibility & Claim Status Operating Rules

Eligibility & Claim Status Operating Rules: Service Type Codes (STCs) Eligibility & Claim Status Operating Rules define some Service Type Codes (STCs) as “discretionary” in the CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules). For certain STCs, the patient financial data is not required to be returned for some benefits Read More →

TMHP EDI

TMHP EDI Overview and Advantage of Electronic Services (Texas Medicaid & Healthcare Partnership) TMHP EDI program and the Health and Human Services Commission (HHSC) encourage providers to submit claims and other requests electronically. Providers can participate in the most efficient and effective method of submitting requests to TMHP by submitting through the TMHP Electronic Data Interchange (EDI) Read More →

CMS Net Provider EDI

CMS Net Provider EDI (Children’s Medical Services Network Provider Electronic Data Interchange) CMS Net Provider EDI is a web-based tool that enables approved CCS and GHPP providers and Medi-Cal Managed Care Plans to electronically access the status of Requests for Services/Authorizations.  Providers and plans have access to view service authorizations, have the ability to print service authorizations, denial Read More →

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 Read More →

ASC X12 Implementation

ASC X12 Implementation Acknowledgement (999) (CAQH CORE Certification) ASC X12 Implementation Acknowledgement (999) must be always returned by CORE-certified organizations. The organization must successfully complete all of the required certification test scripts required by the Phase II CAQH CORE Certification Test Suite to become CORE-certified. The ASC X12 Implementation Acknowledgement (999) can be used only to acknowledge Read More →

X12 Interchange Acknowledgement (250: Claim Status Infrastructure Rule) X12 Interchange Acknowledgement must be returned for real time X12 276 claim status inquiries if the functional group is rejected, or the X12 277 response, to be conformant with this rule. CAQH CORE Rules do not address usage of the X12 Interchange Acknowledgement TA1.  To send real time acknowledgments Read More →

HIPAA CAQH CORE Batch Processing (250: Claim Status Infrastructure Rule) HIPAA CAQH CORE recognizes that every organization has its own record-retention policies and, therefore, does not mandate a strict requirement for retention of response files. However, CAQH CORE recommends that a copy of responses be kept available for a minimum of six months after they Read More →

HIPAA CAQH CORE

CAQH CORE HTTP/S (250: Claim Status Infrastructure Rule) Connectivity CAQH CORE HTTP/S is secure and reliable enough to protect the delivery of healthcare information over the Internet. In Phase I development discussions, CAQH CORE solicited input on this topic from its Technical Work Group members and experts within healthcare and other industries, such as financial services. Based on Read More →