Functional Grouping and Transaction Set File Structure Options (Prevea360 Partner Guidelines) Prevea360 is able to process different variations of transaction sets. Option 1 is the most commonly received structure and is acceptable for files with up to 8000 members. Option 1 (All INS in one ST/SE) Due to system limitations, Prevea360 is unable to process files Read More →

EDI Security

EDI Security-Related Requirements for A/B MACs and CEDI Arrangements With Clearinghouses and Billing Services (Part 1) A billing service is an entity that markets claim preparation services to providers and should also be able to perform related transactions for providers, such as eligibility and claim status inquiries. The billing service collects a provider’s claim information and Read More →

HIPAA Security

HIPAA Security Requirements For Medicare Trading Partners A/B MACs, DME MACs, CEDI, and other entities contracting directly with CMS are considered service providers to CMS. As such, these entities are part of CMS’ system security boundary and must be in compliance with the Federal Information Security Management Act (FISMA) and are subject to CMS security Read More →

HIPAA Transaction Standards

HIPAA Transaction Standards as Designated by CMS HIPAA transaction standards shall be supported by the A/B MACs, DME MACs, CEDI or other contractors if designated by CMS for the electronic data with Medicare providers/submitters/receivers/COB trading partners. ASC X12 Technical Report 3s (TR3s) for mandated HIPAA transactions may be purchased from the official Washington Publishing Company Read More →

Medicare EDI

Medicare EDI Enrollment Information Required EDI Enrollment Information Required for Inclusion at a Minimum in Each A/B MAC, and CEDI EDI Enrollment Form. Medicaid state agencies are not required to complete an EDI Enrollment Form as a condition for receipt of COB claims. In accord with a particular MAC’s business processes, providers who have a signed EDI Read More →

EDI Enrollments

Maintenance of Existing EDI Enrollments The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary’s Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business Read More →

Electronic Remittance Advice

Electronic Remittance Advice (ERA) Enrollment Form The Medicare Electronic Remittance Advice (ERA) Enrollment process provides for collection of the information needed to successfully receive ERA transactions from Medicare and EDI trading partners. This agreement must be executed by each provider that receives ERA either directly to or from Medicare or through a third party. Each Read More →

Claims EDI Processing

HIPAA EDI Legislative Background In The Healthcare Business EDI is the process of using nationally established standards to exchange electronic information between business entities. These national standards are developed and maintained by a group of standards development organizations (SDOs), such as the Accredited Standards Committee (ASC) X12 and the National Council of Prescription Drug Programs Read More →

Medicare EDI Enrollment

New Medicare EDI Enrollments The Medicare EDI Enrollment process provides for collection of the information needed to successfully exchange EDI transactions between Medicare and EDI trading partners and also establishes the expectations for both parties in the exchange. This agreement must be executed by each provider that submits/receives EDI either directly to or from Medicare Read More →

EDI Enrollment

EDI Enrollment Procedures (CMS) A/B MACs and CEDI are required to furnish new providers that request Medicare claim privileges information on EDI. A/B MACs and CEDI are required to assess the capability of entities to submit data electronically, establish their qualifications, and enroll and assign submitter EDI identification numbers to those approved to use EDI. Read More →