EDI Support Frequently Asked Questions

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1 EDI Support Frequently Asked Questions Last revised May 17, This Frequently Asked Question list is intended for providers or billing staff who may or may not have a technical background. General EDI questions 1. What is EDI? 2. HMSA has used the term EMC when referring to electronic claims. Is EDI the same as EMC? 3. What are the benefits of submitting claims electronically? How do I get started? 4. What do I need to send EDI? 5. What clearinghouses can send claims to HMSA? 6. Will HMSA charge me anything for sending EDI? 7. How do I enroll for EDI? 8. How do I fill out the Trading Partner Agreement/Business Associate Authorization form? 9. When can I expect to start submitting electronic claims? 10. I m switching clearinghouses/billing services. Do I need to contact EDI Support? 11. What are the rules for setting the password on the EDI system? Contacting EDI Support 12. How can I contact EDI Support? 13. What information should I give EDI Support? 14. What is the difference between a rejection and a denial? 15. What is HMSA s payer ID? 16. The EDI support technician used a term I don t understand. What are all these terms anyway? Understanding your reports 17. How will I know if my claims have been accepted or rejected? 18. I was told that my Claims Rejected to Provider report is delivered electronically. How do I retrieve and view it? 19. We recently moved and gave our new correct address to Provider Services. Why are our CRTPs still going to our old address? 20. What is the 997 and how do I use it? 21. I submitted a file to you and I see a file in my mailbox ending with an e. What is this?

2 Dealing with common problems 22. I sent claims via EDI and have not received payment for them. When I contact Provider Services they say that they don t have the claim, but our system says that the claims were sent. What s going on? 23. I received error messages on my CRTP saying that the subscriber ID format is invalid. 24. We are receiving errors on the CRTP saying the NPI is not valid/associated with rendering/claimsubmitting. Specific situations 25. We are a federally qualified health center that submits both the CMS 1500 form and UB 04 forms. Can we submit both types of forms to HMSA? 26. Does HMSA allow direct deposit of claim payments to our bank account? 27. Once we re setup for EFT, when can we expect payment? 28. Why aren t we receiving QUEST (or FEP or BlueCard) payments EFT? General EDI Questions What is HIPAA EDI? EDI stands for Electronic Data Interchange, and refers to sending business transactions by electronic means. In the healthcare world, EDI refers to HIPAA EDI: standard formats used for sending electronic claims, receiving remittance information, and getting eligibility and claim status information, among others. The Health Insurance Portability and Accountability Act (HIPAA) requires all providers and payers who do business electronically to use these standard formats when their computers talk to each other. HMSA has used the term EMC when referring to electronic claims. Is EDI the same as EMC? Yes and no. Electronic media claims (EMC), the term HMSA has used in the past, refers specifically to electronic claim submission. Electronic data interchange (EDI), however, is broader and refers to the wider variety of things that can be done electronically, including remittance, eligibility, and claim status. Because of this, HMSA now prefers to refer to its electronic offerings collectively as EDI.

3 What are the benefits of submitting claims electronically? Electronic claims filing is a fast and efficient way to process and submit your claims. By taking advantage of technology and EDI tools, you can lower the cost of a claim and facilitate claims payment. In addition, you could benefit from 24 hours a day claims transmission, electronic acknowledgement of claims received by HMSA and EDI support. Electronic claims tend to be cleaner than paper claims as a result of available EDI tools. This can further improve your efficiency by minimizing payment delays caused by reworking claims. And submitting electronic claims is fast and easy, and allows you to free up time that can be used on other office priorities. Getting started What do I need to send EDI? In order to send EDI to HMSA you will need the following: 1. A practice management software package that is capable of sending HIPAA compliant transactions. Most people will be using EDI to send claims, so you would want to look for software capable of sending HIPAA compliant claim files (also known as 837 files) directly to HMSA, or that connects with a claims clearinghouse that sends HIPAA compliant claim files to HMSA. HMSA s computer systems currently do not support direct data entry of claims (i.e. the ability to enter claim information directly on a web site). However, some clearinghouses that send claim files to us may have similar functionality available. Alternately, you can employ a billing service that has EDI capabilities. 2. Either a dial up modem or an Internet connection, depending on your software s requirements. Check with your software vendor to see what they require. 3. A National Provider Identifier (NPI). This will be submitted on your electronic claim instead of your provider number. So that HMSA can properly identify you on your electronic claims, you will need to give HMSA the NPI for your practice (and the NPIs for any individual providers who work for the practice) if you have not done so already. For information on obtaining an NPI, see National Provider Identifier (NPI). If you do not have a method of billing or have questions about your current billing situation, Ann Yamamoto Wong can help assess your office s needs and suggest appropriate electronic filing solutions. If you have questions about EDI, please contact her at (808) on Oahu or via at Ann_Yamamoto

4 What clearinghouses can send claims to HMSA? HMSA does not require users to use a particular clearinghouse to send claims. We accept claims from a variety of different clearinghouses. For a partial list, contact EDI Support. If the clearinghouse you wish/need to use is not listed, we can provide your chosen clearinghouse with the information they need to successfully send claims, and work with them to test. Have your clearinghouse s technical support area contact HMSA EDI Support to get further details. Will HMSA charge me anything for sending or receiving EDI? No. HMSA does not charge providers for sending or receiving EDI transactions. However, your software vendor or clearinghouse may charge maintenance fees or per claim fees for using their system. How do I enroll in EDI? To enroll with EDI, you need to fill out an Electronic Trading Partner Agreement (TPA) with HMSA. This agreement lays out the responsibilities for sending and receiving information electronically from HMSA, and your signature on the TPA is the equivalent of a signature on your claim forms. If you are currently using the Hawaii Healthcare Information Network (HHIN), you probably filled out a Trading Partner Agreement when you signed up. If so, you need not fill out another one. If you are not sure whether you filled out a TPA, contact EDI Support. They can check. Many clearinghouses will provide HMSA s TPA as part of the enrollment paperwork. If you have enrolled through a clearinghouse and they have not provided you with HMSA s TPA, go to the following link to retrieve a copy: (direct link to TPA) How do I fill out and return the Trading Partner Agreement/Business Associate Authorization form? Complete the Trading Partner Agreement as follows: On page 1: Fill in the blank in the first paragraph with the legal name of your practice. On page 14: Fill in the blanks on the left side authorized signature, name of practice, address, phone number, and date. The agreement must be signed by someone authorized to enter into contracts for the practice. You only need to fill out page 17 (the Business Associate authorization form) if a third party will submit claims or access information on your behalf. Complete the first half with your information and signature, and the bottom half with your business associate s contact information.

5 Send the completed TPA to the following address: HMSA Attn: EDI/HHIN Support P.O. Box 860 Honolulu, HI In addition to sending the TPA by mail, you may also fax the three pages indicated above (1, 14, and 17) to (808) This will expedite your setup process but does not substitute for the original copy. The original copy of the TPA will be signed by HMSA senior management. If you wish, a copy will be returned to you. When can I expect to start sending electronic claims? Expect your EDI account to be ready within five to ten business days of when HMSA receives your enrollment paperwork. You (and your clearinghouse, if you have one) will be notified when your setup is complete. Also work with your practice management software vendor and/or clearinghouse to assist in setup. If you would like us to give you feedback on your first electronic transmission, contact us at , toll free at or via at I m switching clearinghouses/billing services. Do I need to contact EDI Support. Yes. We need to know so that we can set up your EDI correctly. Changes to your business associate arrangement usually require us to make changes on HMSA s system. If you re already submitting EDI and have already submitted a valid TPA, you can let us know by sending another Business Associate Authorization form with the new business associate s information. You need not send the entire TPA again. What are the rules for setting the password on the EDI system? On the dialup system, the password needs to be at least seven characters long and have a combination of three of the following four categories: number, uppercase letters, lowercase letters, and nonalphanumeric symbols. The system will not allow you to reuse the last five passwords. On the secure FTP system, the password needs to be at least eight characters long, and have at least two letters, one number, and one non alphanumeric symbol. Password are valid for 60 days on secure FTP or 90 days on dialup, after which they need to be changed.

6 Contacting EDI Support How can I contact EDI Support? You can contact any EDI Support representative in any of the following ways: On Oahu: (808) Outside Oahu: (800) What information should I give EDI Support? When calling EDI Support, have the following information ready for the most efficient service: 1. A detailed description of your issue. Include any error messages that you receive. 2. If your system submits directly to us, your HMSA assigned submitter ID/user ID. 3. Your HMSA provider number(s). 4. Your NPIs. 5. Any related reports that you may have received from HMSA and/or your clearinghouse. 6. If you are calling regarding claims, information on the claim(s) in question (name, member ID, date of service, amount). If it involves a large number of claims, let us know how many claims are affected and have one or two example claims for the technician to check. 7. If you are calling regarding remittances, information on the payment (payment date, amount, check number, line of business, and the payee number). 8. A contact number or e mail address that the EDI Support representative can reach you at. What is the difference between a rejection and a denial? As EDI Support uses these terms: A claim is rejected if there is a problem with a claim that violates the rules of the HIPAA standard, or which otherwise does not comply with HMSA s basic requirements for claim submission. Examples of rejection reasons include missing information, invalid ID formats, or invalid diagnosis or procedure codes. These claims will usually appear on the Claims Rejected to Provider report (see below). Rejected claims must be corrected and resubmitted; they have not been sent to HMSA s adjudication system and will not be processed. If you call HMSA s Provider Service Teleservice line for more information on rejected claims, it will look to them like you never submitted the claim. Only EDI Support will be able to troubleshoot these claims. If you have a question on a rejection, contact EDI Support directly. A claim is denied if, after adjudication and evaluation, it is determined that no payment will be made on a claim. It could be because the claim is deemed not medically necessary or is otherwise ineligible for payment by HMSA medical policies, or because more information may be needed for payment (e.g. missing primary payment information for coordination of benefits). Denials would appear on the Report to Provider (RTP). For questions on denials, first contact

7 Provider Services Teleservice at (808) or (800) They will refer you to EDI Support if necessary. What is HMSA s payer ID? It depends on the context: 1. Usually we hear this question when a provider wishes to send claims through a clearinghouse. In this case, the payer ID is actually a number that is assigned to HMSA so that claims sent through the clearinghouse are directed to us. Often, this would be published in a list created by the clearinghouse and made available on the clearinghouse s Web site you should check your clearinghouse s Web site for this information. Note that HMSA may be listed in payer lists under any of the following names: HMSA (abbreviated) Hawaii Medical Service Association (spelled out) Blue Cross/Blue Shield of Hawaii (or similar names) 2. In the context of Medicare, it may refer to the number that identifies us for HMSA crossover claims: a for Federal Employee Program b for HMSA 65C Plus c for HMSA PPO/HMO 3. Otherwise, it may refer to the number used to identify us in direct claims, which is our tax ID number If you have any other questions, please call EDI Support for assistance. The EDI support technician used a term I don t understand. What are all these terms anyway? EDI has its own specialized language, and your EDI representative may use such terms in describing your issue. He or she will be happy to clarify any terms you don t understand, but here are a few you may encounter and examples of how it will be used: 837 A HIPAA standard EDI claim file. I ll need to look at your 837 to figure out what s wrong. 835 A HIPAA standard electronic remittance file that you can load to post your payments. Could I get the check number so I can find your 835? 997 The functional acknowledgment that is sent after a file comes in. A 997 did come out when you sent your file; that s a good sign. Tumbleweed Refers to our secure FTP/Web based claim submission system. Named for the vendor that supplies it (which you can see if you go to pidx.hmsa.com). Are you able to log into Tumbleweed?

8 Loop X, segment Y Describing a standard place in the file that contains information. Normally your EDI technician will avoid describing your problem this way if it can be described more simply. Your technician will describe it this way if he or she wants you to notify your software vendor of a problem. Given this information, your software vendor or clearinghouse may be better able to diagnose your problem. Understanding your reports How will I know if my claims have been accepted or rejected? When HMSA received an EDI batch, we send back information on the claims received so that any errors can be corrected and resubmitted. This also serves as a confirmation that the claims were received. For direct submissions, this information is in the form of the Claims Rejected to Provider report (CRTP), which can be sent back either via postal mail or electronically (see question below). On the report will be summary totals of the number of claims received and the number of claims accepted and rejected, which will look like this: TOTALS CLAIMS CHARGES PERCENT CLAIMS IN ERROR % CLAIMS ACCEPTED 38 $4, CLAIMS IN BATCH 38 $4, If no claims are in error, you may assume that the batch is processing successfully. (There is a slight possibility that your file may run into problems further on in the process. Should this happen, we will make every effort to notify you as soon as possible to take corrective action.) If any claims are identified as being in error, they will be listed on separate pages with the name, member ID number, dates of service, and reason for rejection. See the following list of commonly encountered error messages on the CRTP. If you do not understand a rejection message, call EDI Support for assistance and be prepared to give them the information from the CRTP. In most cases, only the rejected claims need to resubmitted, unless an error message specifically says that the entire batch needs to be resubmitted. Rejected claims can be resubmitted electronically if your software allows it (contact your software vendor if you are not sure). If you send your claims via a clearinghouse, your clearinghouse may also send back this information to you formatted as a report from your clearinghouse. If you do not receive a paper CRTP and do not

9 receive rejection information from your clearinghouse, contact your clearinghouse to see how you can get this information sent to you. I was told that my Claims Rejected to Provider report is delivered electronically. How do I retrieve and view it? Your software may be able to retrieve these files and make them readable. If not, and you are able to directly access your account using a terminal program such as Hyperterminal or via the web, here is how to view the files. On dialup You will need the following three files: crtpsc.xsl, crtpsc.css, and hmsalogo.jpg. These three files may be in your dialup account. Download these three files to a folder on your computer. If you don t see these files, contact EDI Support. Electronic CRTPs come in two forms: JX files these have file names starting with jx and end in XML, such as jx0128op.01.xml. JC files these are plain text files with filenames starting with jc, from our old mainframe system. Download the ecrtps to the same folder that contains the three files you downloaded earlier. Once there, to view the files, do the following: JX files: double click the files; it should open your web browser and the file will come out nicely formatted. JC files: Open the file in any word processor or text editor. On Tumbleweed Electronic CRTPs on Tumbleweed are compressed using the GZIP algorithm. Do not confuse this with the PKZIP algorithm (.ZIP file) that is the standard on Windows PCs. In order to view these, download the files to the folder that contains the three support files, as described above. Then use a program that can decompress GZIP files to convert them into usable files. (WinZip, a popular decompression utility for Windows PCs, can decompress GZIP.) Once decompressed, you may open them in your web browser or text editor as above. We recently moved and gave our new address to Provider Services. Why are our CRTPs still going to our old address? The CRTP relies on an address database that EDI Support maintains. It is separate from the databases that the Provider Data and Contracting Administration (PDCA) unit maintains. Some providers have

10 third party billers, and some of these billers have requested that they receive the CRTP on behalf of the provider, so we need to keep the address databases separate. If you have changed your mailing address, please notify the EDI Help Desk as soon as possible so that we can update our records and ensure your CRTP goes to the correct address (and avoid possible privacy exposures). For the same reason, also be sure to inform us if: you hire a billing service or clearinghouse, change billers or clearinghouses, or take the billing inhouse, or you have any changes to your HMSA provider numbers and/or NPIs. You may have to fill out additional paperwork to document the change. EDI Support will let you know what forms you need, if any. What is the 997 file and how do I use it? When you send an EDI claim file or other EDI transaction to HMSA, our system performs initial processing on it, and in the process, it generates a transaction file known as the Functional Acknowledgement, or 997. The file contains information on whether the file was accepted into the system, and also information on errors in your file. As with most EDI transactions, the 997 is designed is be read by a computer system. On many systems you can download this 997 and load it into your computer, and it will read the information and make it human readable. If for some reason your system doesn t read 997s, it is possible to open the file in a word processor like Microsoft Word or a text editor such as Notepad and get some information on the status of your transmission. A typical 997 looks like this when opened: ISA{00{ {00{ {30{ {ZZ{XXXXXX {110103{0902{U{00401{ {0{P{: GS{FA{CLM{ACC{ {090242{ {X{004010X098A1 ST{997{0001 AK1{HC{ AK2{837{ AK5{A AK9{A{1{1{1 SE{6{0001 GE{1{ IEA{1{ The important thing to check are the lines beginning with AK5 and AK9 (also known as the AK5 and AK9 segments). In those lines you want to check the letter after the curly brace:

11 A means that the file has no HIPAA technical errors and has been accepted into the system for processing. R means that the file has one or more HIPAA technical errors and one or more claims have been rejected for not being HIPAA compliant. (NOTE: In our system, this does not necessarily mean that the entire file has been rejected.) If you do not receive either a 997 or an e file after submitting a file (described below), contact EDI Support for assistance. I submitted a claim file to you and I see a file in my mailbox ending with an e. What is this? This means that the claim file that you sent has a problem that cannot be described by the 997. You can find out the problem by downloading the file and opening it. A typical e file looks like this when opened: 01/29/2011**scc001:ca0129ip.03z aud.dfc*SCC001 * *P*Duplicate File The reason is described at the end of the line. It can be any of the following: Duplicate file Reason: Your system sent a file that may be a duplicate. The system uses the interchange control number a number automatically assigned to your file by your software as a check against duplicates. Usually this means the file is a duplicate, but it is possible for your software to send a file that is not an exact duplicate but just happens to have the same control number as a previous file. Action: Check to see if you may have inadvertently sent a file twice. If not, contact EDI Support or your software vendor for assistance. Reject Data Reason: There is an unspecified technical problem with your file. There may have been an interruption in your data stream or a structural problem with your file. In any case, the EDI system cannot process your file. Action: Contact EDI Support for assistance. They will check your file and attempt to pinpoint the problem. File not a valid EBCDIC file Reason: Usually occurs on files that have been compressed; the system could not decompress the file. There may be a problem when your system compressed the file. Action: Try to resend the file in question. If the problem persists, contact your software vendor for assistance.

12 Invalid or missing element Reason: There is a technical problem with the file a necessary piece of information is missing. Action: Contact your software vendor for assistance. Dealing with common problems I sent claims via EDI and have not received payment for them. I contacted Provider Services and they say that they don t have the claim, but our system says that the claims were sent. What s going on? Very likely Provider Services would refer you to EDI Support if you re in this situation. It s possible that the claims were not received by us, but it s also possible (and more likely) that something may have been wrong with the claim or the claim file, and it may have been rejected by our EDI system. Ordinarily this would be reported on the Claims Rejected to Provider report and sent to you. Provider Services can only see claims that are in the adjudication system, and rejected claims don t make it that far. Therefore, Provider Services would not be able to see the claim. EDI Support, however, can check your original claim files and verify receipt and disposition. First, check to see if you are receiving the CRTP or any other rejection information, either via the mail or electronically. The date of the report normally corresponds to the date that HMSA received the claims. You should receive the report no later than a week following submission. If you have not received any reports, check the claim itself: 1. Ensure that the member ID is in the correct format for the line of business (see below). 2. Ensure that all names, addresses, and dates of birth and service are valid. 3. Ensure that the correct NPIs appear on the claim. 4. Ensure that all diagnosis and procedure codes are valid for the date of service. (One common error is failing to provide a 4 th or 5 th digit on the code when one is required.) If all looks OK, contact EDI Support for assistance. Have the following information available for the technician: 1. If you submit directly to us and not through a clearinghouse, your HMSA submitter ID. 2. If you submit through a clearinghouse, the name of the clearinghouse and your HMSA provider number and/or NPI. 3. Whether or not you are receiving the Claims Rejected to Provider report or other rejection information from your software or clearinghouse. 4. The particulars on the claim in question (name, member ID, date of service), and approximate date of submission.

13 I received error messages on my CRTP saying that the subscriber ID format is invalid. Ensure that the subscriber IDs are in the correct format for the line of business, as described below. (This may be different from how you submitted the IDs on paper forms in the past.) For HMSA PPO (including Federal Plan 087), HMO, 65C Plus, and Akamai Advantage: One letter followed by 12 digits. Include all leading zeroes. Do not include the BlueCard prefix (the first three letters). For example: If the card says XLHR , send R For HMSA QUEST: Ten digits. Include all leading zeroes. Do not include the BlueCard prefix (the first three letters). For example: If the card says XLQ , send For the Blue Cross Blue Shield Federal Employee Program (FEP): The letter R followed by eight digits. Send exactly as shown on the card. Example: R Note: Most PPO and HMO members have the letter R and four leading zeroes. For PPO and HMO members, be sure to send all leading zeroes. Otherwise, the number will resemble an FEP number and be routed there, causing claim denials. For out of state BlueCard plans: Send the entire number as listed on the card. We are receiving errors on the CRTP saying the NPI is not valid/associated with rendering/claim submitting. This situation has a number of possible causes: 1. You have a Type 1 or Type 2 NPI and submitted your claim using it, but HMSA does not have it listed in its system. 2. You submitted both Type 1 and Type 2 NPIs to HMSA and our system is expecting both, but you submitted using only one or the other. 3. You made a mistake in entering the Type 1 NPI, the type 2 NPI, or both, in your system. Whether your system or our system (or both) needs correcting depends on several factors: 1. What NPIs you have. 2. Whether you have shared those NPIs with HMSA. 3. Whether Medicare requires you to send claims with just the type 1, or both type 1 and 2. (Medicare generally forwards its HMSA secondary claims to us automatically. Generally HMSA needs to have the same NPIs that Medicare has in order to process crossover claims correctly.)

14 If your claims are rejecting because of any of these problems, or you are getting returned claims due to invalid or missing provider numbers, contact EDI Support for assistance. Be prepared to tell the technician what NPIs you have, and which NPIs Medicare requires of you. The technician will check your files and recommend further action, which may include: 1. Correcting the NPIs in your system. 2. Sending the NPPES letter listing the missing NPI to EDI Support, who will forward it to Provider Data and Contracting Administration for processing. EDI Support will notify you when the new NPI can be used in an EDI claim. Do not resubmit your claims electronically using your HMSA provider (legacy) number. These will be rejected. Specific situations We are a Federally Qualified Health Center that submits both the CMS 1500 professional claim form and UB 04 institutional form. Can we submit both types of claims to HMSA, or just one or the other? You can submit both types using one account. However, please let us know if this is the case so that we can configure your account correctly. Does HMSA allow direct deposit of claim payments to our bank account? HMSA does offer electronic funds transfer (EFT) for qualified providers. To qualify, you need to be setup with electronic claims and electronic remittance. Contact EDI Support for the application form, which you will need to complete and return with a voided check or deposit slip attached. (If using a deposit slip, be sure the routing number on the deposit slip matches the one on the check.) EDI Support will review your application and send it to Finance and Accounting for processing. There is a two week testing period (called pre notification) where the EFT process is tested. You may see zero amount transactions on your bank statement, this is normal. Expect your first EFT transfer within two to three weeks of your application. Once our EFT is active, when can we expect payment? HMSA sends out its EFT payments in the morning of the scheduled payment date. Depending on your financial institution, it may reach your account as early as the next day, but it may take longer.

15 Why aren t we receiving QUEST (or FEP or BlueCard) payments EFT? Currently EFT is available only for HMSA commercial plans (PPO and HMO) and for HMSA senior plans (65C Plus and Akamai Advantage).

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