Chapter. 21TMHP Electronic Data Interchange (EDI)

Transcription

1 Chapter 21TMHP Electronic Data Interchange (EDI) TMHP EDI Overview Advantages of Electronic Services Getting Help Electronic Services Available The TMHP Website Publications File Libraries Search Capabilities for the CSHCN Provider Manual Part I Step 1 Choose How Claims Will Be Submitted Software TDHconnect Vendor Software Billing Agents Step 2 Setting up Access Step 3 Training Request for Electronic Transmission Reports Vendor Implementation Supported File Types Forms

2 Chapter TMHP EDI Overview Providers may submit claims and other requests using paper forms or faster electronic methods. The Health and Human Services Commission (HHSC) and TMHP 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) claims processing system. TMHP uses the Health Insurance Portability and Accountability Act (HIPAA) compliant American National Standards Institute (ANSI) ASC X A file format through secure socket layer (SSL) and virtual private networking (VPN) connections for maximum security. Providers can access TMHP s electronic services through TDHconnect, vendor software, and billing agents Advantages of Electronic Services It s fast. No more waiting by the mailbox or making telephone inquiries; know what s happening to claims in less than 24 hours and receive reimbursement for approved claims within a week. TDHconnect users can submit individual requests interactively and receive a response immediately. It s free. All electronic services offered by TMHP are free, as well as the TDHconnect software and it s technical support, upgrades, and training. TDHconnect users can access the TMHP website directly, without having to pay for an internet connection. It s easy. TMHP offers free workshops for TDHconnect, Medicaid and CSHCN Services Program billing, and many other topics, as well as a large library of reference materials and manuals on It s safe. TMHP EDI services use VPN and SSL connections, just like the U.S. government, banks, and other financial institutions, for maximum security. It s accurate. TDHconnect and many other software programs have features that let providers know when they ve made a mistake, which means fewer rejected and denied claims. Rejected claims are returned with messages that explain what s wrong, so the claim can be corrected and resubmitted right away. It s there when it s needed. Electronic services are available day and night; from home, the office, or anywhere in the world. It makes record keeping and research easy. Not only can software be used to send and receive claims, it can retrieve Electronic Remittance and Status (ER&S) reports, perform claim status inquiries, and archive claims. TDHconnect can generate and print reports on everything it sends, receives, and archives Getting Help Contact the TMHP EDI Help Desk at or visit the TMHP website at for more information about EDI services. The TMHP EDI Help Desk does not provide training. Providers should contact their TMHP provider relations representative or attend one of the training workshops provided by TMHP Provider Relations. Additional information about training opportunities is available on the TMHP website at C18/Workshops. For answers to program related questions, call the TMHP-CSHCN Contact Center at Electronic Services Available Eligibility verification (EV) Claims submission Claim status inquiry (CSI) ER&S reports Appeals 21 2

3 TMHP Electronic Data Interchange (EDI) 21.3 The TMHP Website The TMHP website at is a valuable resource that provides: Information and registration for upcoming provider education/training sessions A file library that contains publications, such as bulletins, banner messages, and provider manuals A Headline News section with announcements of current and upcoming program changes and other important information TDHconnect 3.0 updates (service packs) Forums, polls, and questionnaires Additional advanced features are available for those providers who create an account. There is no charge for opening an account on the TMHP website. All enrolled providers are eligible for this service. Once an account is activated, providers will have access to: Medicaid and CSHCN enrollment information Claim status inquiry (CSI) Eligibility verification (EV) Electronic remittance and Status (ER&S) report download option Complete instructions for setting up a Provider Administrator account and the use of online CSI, EV, and ER&S reports. New services continue to be added to the website. Visit or call the EDI Help Desk at for the latest information about online services Publications All providers have access to the publications available on the TMHP website, including the CSHCN Provider Manual Part I, Texas Medicaid Provider Procedures Manual, and bulletins. These items are available in the TMHP File Library. Use the following steps to access the TMHP File Library: 1) Access the TMHP website at The TMHP Homepage opens. 2) Click the Find Publications/File Library link in the I would like to links on the upper right-hand corner of the page. The TMHP File Library webpage opens. 3) Use the links on the TMHP File Library webpage to locate specific publications File Libraries The file libraries contain useful reference materials. Some of the libraries are: Banner messages a weekly history of banner messages Bulletins CSHCN, Long Term Care, and Medicaid bulletins CSHCN Family Newsletters EDI reference and connectivity guides Fee schedules Provider manuals TDHconnect software updates Search Capabilities for the CSHCN Provider Manual Part I The online version of the CSHCN Provider Manual Part I is available in portable document format (PDF), viewable in Adobe Acrobat or Reader. The Bookmarks window located on the left side of the screen provides a link to each heading within the manual. Click on the heading/link to quickly access the topic of interest. Use the following instructions to search the online version of the manual by a keyword or phrase: 1) Click the Find icon (binoculars) in the toolbar located at the top of the page. The Acrobat Find window opens. 21 3

4 Chapter 21 2) In the Find What window, enter a keyword or phrase. Choose one of the following options if applicable to the search: Match whole word only Match case Find backwards Ignore Asian character width 3) Click Find. The cursor moves to the first place within the manual where the word or phrase appears. 4) To continue searching for the same keyword or term, click the Find Again icon (binoculars with an arrow) located in the toolbar at the top of the page Step 1 Choose How Claims Will Be Submitted Providers who wish to transition from paper billing to electronic billing should decide how they will submit their claims to TMHP. Providers can either use software to submit files directly to TMHP or they may use a billing agent (i.e., billing companies, vendors, or clearinghouses) who will submit files on the provider's behalf Software Providers that intend to use TMHP s electronic services will need software to create, submit, and retrieve data files. Providers can use TDHconnect (TMHP s free software) or the software can be from any vendor listed on the EDI Submitter List at Providers who plan to use a billing agent to submit EDI transactions to TMHP should contact that organization for details on software requirements TDHconnect TDHconnect is the versatile, reliable, and free Windows based claims submission software provided by TMHP. Technical support, upgrades, and training for TDHconnect are also available free from TMHP. TDHconnect has a wide variety of features, some of which are not available in most vendor software. Providers can use the software to submit claims, eligibility requests, claim status inquiries, adjustments, appeals, and retrieve ER&S reports. The program includes a reference database of current billing codes, procedure codes, Explanation Of Benefit (EOB) codes, and much more. Providers can even use TDHconnect to interactively submit individual claims that are processed in seconds. To order TDHconnect or to learn more about the program, visit the TMHP website at call the EDI Help Desk at , or use the TDHconnect Order Form on page C-57. Before attempting to install TDHconnect, verify that the computer on which it will be installed meets the minimum software and hardware requirements listed on the order form. TDHconnect 3.0 is not supported on non- Windows operating systems or on systems that do not meet the minimum system requirements. Important: A basic knowledge of Windows operating systems is required to use TDHconnect 3.0. TDHconnect 3.0 works with a standard telephone line and existing internet connections. Providers in rotary dial areas cannot use the direct dial features of TDHconnect 3.0 but may use another existing internet connection. Microsoft and Windows are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries Vendor Software Providers may also use vendor software to access TMHP s electronic services. There are hundreds of vendors with a wide assortment of services that have been approved to submit electronic files to TMHP. A complete list of vendors who have completed the testing process and been certified by TMHP can be found at TMHP does not make vendor recommendations or provide any assistance for vendor software. Not all vendor software offers the same features or levels of support. Providers are encouraged to research their software thoroughly to make certain it will meet their needs and that it has completed testing with TMHP. 21 4

5 TMHP Electronic Data Interchange (EDI) Billing Agents Billing agents are companies or individuals who submit electronic files to TMHP on behalf of the provider. Generally, this means that the provider uses a product that sends billing or other information to the billing agent who processes it and then transmits it to TMHP and other institutions. TMHP has no information on the software or other requirements of billing agents. Providers should contact the billing agent to obtain information about their products and processes. A complete list of billing agents who have completed the testing process and been certified by TMHP can be found at TMHP does not make billing agent recommendations or provide any assistance for billing agents software or services. Note: Vendors should refer to Section 21.8, Vendor Implementation, on page Step 2 Setting up Access Providers must setup their software or billing agent services to access the TMHP EDI Gateway. Providers who use billing agents or software vendors should contact those organizations for information on installation, settings, maintenance, and their processes and procedures for exchanging electronic data. Providers who use TDHconnect may use the Quick Start Guide that accompanies the software or contact the EDI Help Desk at After TDHconnect is installed, providers can access the help manual built into TDHconnect by clicking on the Help button and selecting Contents and Index. Providers who use TDHconnect or vendor software must also request a submitter ID. A submitter ID is necessary for all of TMHP s electronic services. It serves as an electronic mailbox for the provider and TMHP to exchange data files. Providers must call the EDI Help Desk at to order a submitter ID. Providers who use a billing agent do not need a submitter ID Step 3 Training Providers should contact their TMHP provider relations representative or attend one of the training workshops provided by TMHP Provider Relations to receive training for TDHconnect or other billing issues. Additional information about training opportunities is available on the TMHP website at Providers may also use the many reference materials available on the website in the file library section, see Section , Publications, on page For answers to program related questions, call the TMHP-CSHCN Contact Center at Request for Electronic Transmission Reports Providers are required to retain all claim and electronic file transmission records. Providers must verify that all claims submitted to the CSHCN Services Program or its agent are received and accepted. Additionally, providers must also track claims transmissions against claims payments to detect and correct all claim errors. Refer to: Section 3.2, Provider Responsibilities, on page 3-5, for more information about provider responsibilities and electronic submissions. When an electronic file transmission record is missing, providers can request a copy of the transmission report(s) by contacting the TMHP EDI Help Desk at and requesting the transmission reports order form. Requests for transmission reports produced in the previous 30 days will be provided at no cost to the providers. Requests for transmission reports produced more than 30 days before the request will result in a charge of $500 plus 8.25 percent sales tax of $41.25 for a total charge of $ Providers that hold a tax-exempt certificate will not be assessed the 8.25 percent sales tax. This cost is per transmission report. Provider payment will be required with the submission of the completed transmission order form to TMHP Vendor Implementation TMHP requires all software vendors and billing agents to complete EDI testing before access to the production server is allowed. Vendors who wish to begin testing may either call the EDI Help Desk at or visit the EDIFECS testing site at and use the TMHP Support link. An EDIFECS account will be created for the vendor to begin testing EDI formats. Upon successful completion of EDIFECS testing and the submission of a Trading Partner Agreement, vendors 21 5

6 Chapter 21 must then complete end-to-end testing on the TMHP test server. Vendors (billing agents) must be partnered with at least one Texas provider before a Test Submitter ID can be issued. Once end to end testing has been completed, the billing organization/agent will be added to the EDI Submitter List. Providers and billing agents may then order Production submitter ID s for use with the vendor s software Supported File Types TMHP EDI supports the following electronic Health Insurance Portability and Accountability Act (HIPAA) compliant transaction types: Electronic Transaction Types 270 Eligibility request 271 Eligibility response 276 Claim status inquiry 277 Claim status inquiry response 835 ER&S report 837D 837I 837P Dental claims Institutional claims Professional claims Forms The following forms are available in Forms and Form Examples, on page C-1: Claim Status Inquiry (CSI) Authorization on page C-54 Electronic Remittance and Status (ER&S) Agreement on page C-55 TDHconnect Order Form on page C-57 Note: Photocopy these forms and retain the originals for reuse. 21 6