EDI Solutions Your guide to getting started -- and ensuring smooth transactions empireblue.com/edi 00175NYPEN Rev. 12/11
This brochure is a helpful EDI reference for both new and experienced electronic submitters. It covers the basics, like choosing an electronic filing approach and what to ask potential vendors. It also includes tips for keeping your transactions running smoothly, no matter how long you ve been submitting electronically. And, it can help point you in the right direction when you need more detailed answers about processes, reports or other questions that may arise. Remember to consult this guide, or visit empireblue.com/edi whenever you have questions. Should I handle electronic submissions directly or work with an EDI vendor? Every practice or facility must manage its own unique set of marketplace requirements, operational needs and system capabilities. Using EDI Solutions, you can conveniently submit electronic transactions to us via a process called Electronic Data Interchange (EDI) an advanced form of electronic business-to-business communication linking providers to EDI vendors, software vendors, clearinghouses or billing agencies and Empire. To prepare your office for electronic submission, below are descriptions of two basic approaches. Using an EDI vendor, clearinghouse or billing agency If you choose this approach, you ll submit either paper or electronic information to an EDI vendor of your choice. The EDI vendor then submits transactions to us. Generally, EDI vendors can supply you with everything necessary to edit, format, file and reconcile transactions electronically. EDI vendors often offer solutions that adapt well to your current practice management systems with little or no changes to your internal office procedures. Services to look for in an EDI vendor Mechanisms to ensure claims are directed to the appropriate payer Payer front-end editing, registration and testing Mechanisms to ensure current and valid codes are submitted such as CPT, HCPCS, CDT, ICD-9-CM and NDC (national drug codes) Systems to ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements, maintaining HIPAA certification as needed Customer support, training and service-level agreements Mechanisms to monitor state, federal and payer filing specifications, installing system upgrades as appropriate Clear, accurate and easy-to-use reporting Electronic pick-up and delivery for transactions 21 Help Desk 866-889-7322
Services to look for in an EDI vendor (continued) Service-level agreements are between you and your EDI vendor. They are the first point of contact for electronic questions. Likewise, we also contract directly with each EDI vendor to ensure appropriate HIPAA and Empire formatting. EDI Solutions provides customer support, electronic filing instructions (Empire Companion Guide) and daily reporting for our contracting EDI vendors. You can find our electronic submitter contractual agreements, an EDI vendor listing, additional EDI vendor descriptions and electronic filing instructions at. NOTE: EDI vendors, clearinghouses and billing agencies described offer a wide variety of services. While some provide all the ones mentioned above, others may not. Please work directly with your selected EDI vendor to determine their capabilities. Submitting directly You re also welcome to contract and submit directly to Empire through EDI. Generally, you re responsible for editing, formatting, filing and reconciling your submissions according to HIPAA and Empire specifications, using software designed and supported by your own organization or by a software vendor. With the direct submission approach, you must use your own computer, modem, communications software and data compression software. There is no cost to submit claims electronically to us, beyond what is needed to prepare and maintain your environment. EDI Solutions provides customer support, electronic filing instructions (Empire Companion Guide) and daily reporting. You can find our electronic submitter contractual agreements and the Empire Companion Guide online at. To submit directly, you should have: Experienced EDI staff to help with the submission and reconciliation of electronic submissions Ability to monitor state and federal mandates, providing the necessary support for system modifications Systems to ensure electronic transactions are HIPAA-compliant Mechanisms to ensure that current and valid codes are submitted such as CPT, HCPCS, CDT, ICD-9-CM and NDC Ability to accept and interpret electronic acknowledgements and reports when transaction fail HIPAA compliance Ability to monitor payer communications for potential system upgrades } } Technology available to support data compression and connectivity software needed for electronic submission Help Desk 866-889-7322 32
Consider these features when choosing your approach HIPAA-compliant format, code set editing such as CPT, HCPCS, CDT, ICD-9-CM and NDC and support for state and federal mandates Ability to access secured patient insurance eligibility, benefit and claim inquiries which provide access to membership, copays, benefits and deductible amounts Ability to submit all claim types electronically coordination of benefits (COB), notes (NTE), adjustments, and institutional and professional claims Customer support and service-level agreements Editing to ensure the accuracy of NPI numbers and payment indicators submitted Automated system capability to correct claim errors and resubmit claims electronically EDI vendor capability to receive and forward important vendor and payer communications Ability to submit to multiple payers Accurate, clear and easy-to-use reports with audit trails to reconcile electronic submissions from your office to the EDI vendor and from the EDI vendor to the payer 835 payment advice (electronic remittance voucher) retrieval and automated posting Patient account information (benefits and eligibility, claim status, fee schedule information and payment history) Training program and user manuals Ability to convert to paper, as appropriate Make an informed decision Determine your needs. Ask the right questions. Here are some tips that can help you make the choice that s right for you. Ask other doctors and facilities how they handle electronic submission Visit for a list of clearinghouses, software vendors and billing agencies Estimate the number of claims you submit each month to various carriers, such as Medicare, Medicaid, Empire and commercial carriers Determine whether your practice or facility has the technical resources to file transactions electronically Determine the approach that best suits your organization s needs Compare the cost and benefits of electronic filing versus paper submissions Get the full benefit of electronic submission by understanding the types of claims your office is likely to submit, such as coordination of benefits (COB), and work with your EDI vendor to move from paper to electronic filing 43 EDI Help Help Desk Desk 866-889-7322
Questions to consider when selecting either approach: Since Empire requires that HIPAA electronic submissions must be certified, what measures are in place to ensure HIPAA compliance? How long will it take to transition from paper to electronic submission? What are the costs involved? With the implementation of HIPAA, claims with coordination of benefit information, adjustments and attachments are now features of electronic filing. What mechanisms are in place to accommodate these features? What options are available if a vendor cannot submit these kinds of claims electronically? Is training available for new or existing employees either on site, via monthly newsletter updates or user group meetings? What costs are associated with training? Is it necessary to purchase additional software and/or hardware to meet the needs of the practice or facility? Are systems unavailable for electronic submissions when system upgrades are installed? Is there a cost for system upgrades? How often are upgrades installed? Is there a capability to automatically post the electronic 835 payment advice? What are the costs involved? Are there software edits that will prevent the submission of invalid, incomplete or inaccurate information? Is the purchased software compatible with the internal computer s operating system (DOS, Windows, MacIntosh, or Unix)? } } Will the HIPAA reports payers are using (such as 999) be translated into a flexible, easy-to-follow format? Help Desk 866-889-7322 54
Questions to consider when selecting either approach (continued): Regarding data transmissions, how are occasional discrepancies between vendors and payers resolved? Is the actual data sent to or from the payer available? How are vendor versus payer errors indicated on an error report? Receiving prompt payments is an important benefit. Are there specific situations that require paper claim submission to a payer? If yes, how will the claims be flagged? Will an indicator note electronic versus paper submissions? Is there an additional cost when paper claims are mailed? What is the vendor s customer support policy? Is support billed at a flat monthly fee or charged on a call-by-call basis? Will the system allow electronic re-transmission of corrected claims, or must these claims be re-billed on paper? Will this software support additional HIPAA mandates, such as electronic attachments? In order to submit electronically with the software purchased, is it also necessary to select a clearinghouse? Is there a client reference list available? What are the service-level agreements and response time frames? What mechanisms are in place to ensure optimal efficiency of your electronic claims process minimizing the need for paper submissions? How will the EDI vendor forward important payer communications? Viewing these communications will allow providers to evaluate and plan for system upgrades and become aware of EDI-related developments. 65 Help Desk 866-889-7322
Your gateway to electronic data sharing Visit At Empire, we ve dedicated a website to share electronic information with you or your electronic data interchange (EDI) vendors (clearinghouses, software vendors and billing agencies). Our website gives you pertinent and timely information, along with helpful tools to ease electronic transactions. Just go to. What you ll find online: EDI registration information and forms EDI contacts and support information EDI communications and electronic submission tips Information on electronic filing benefits and cost-savings Online tools for submitting electronic CMS-1500 claims directly to us at no charge to providers Filing instructions for EDI submission of eligibility, benefit and claim status inquiries Empire Companion Guide with complete information on submitting electronic transactions Empire report descriptions List of clearinghouses, software vendors and billing agencies FAQs and answers about electronic transactions Information and links pertaining to the Health Insurance Portability and Accountability Act (HIPAA) Contractual agreements with our trading partners Help Desk 866-889-7322 67
Questions? Find detailed answers at empireblue.com/edi The Empire Companion and EDI User Guides have the details on how to submit, receive and troubleshoot electronic transactions required by HIPAA. You can find them online at empireblue.com/edi. Whether you submit directly to us or use a clearinghouse, software vendor or billing agency, the Empire Companion Guide and the HIPAA Technical Report 3 (TR3) are effective tools to help address your questions. The more you understand how we process electronic transactions, the better your experience with electronic transactions will be even if you use and outside service. Here s a sample of what you ll find in the Empire Companion and EDI User Guides: Questions Answers Do you accept coordination of benefits (COB) claims? What information is required when filing COB claims electronically? What is the process for sending notes? 837P Health Care Claim Companion Document 837I Health Care Claim Companion Document What is the registration process for receiving 835 payment advices (electronic remittance vouchers)? When are 835 payment advices delivered? What information does Empire provide on the 835 payment advice? Can I request eligibility, benefits and claim status inquiries using EDI? Do you accept both real-time and/or batch inquiry requests? How can I learn more about your enhanced information returned for eligibility, benefit and claim status inquiries? What are the connectivity options for membership eligibility, benefits and claim status inquiries? What reports are provided for trading partners? How often are reports produced? When are the reports delivered? When reports are returned with errors, what is the process for resolving these errors? 835 Health Care Claim Payment/Advice Companion Document 270/271 Eligibility Companion Document 276/277 Claim Status Companion Document EDI User Guide Acknowledgement and Reports 8:00 a.m. 4:30 p.m. ET When are the EDI Solutions specialists available to address questions? What are the hours of operation for the EDI Help Desk? Phone: 866-889-7322 E-mail: edi-ny @empireblue.com Web: empireblue.com/edi 87 Help Desk 866-889-7322
Reports help speed account reconciliation Accurate, timely reports help resolve errors early Timely reporting lets you quickly correct errors so you can re-submit electronic transactions quickly speeding account reconciliation. The two-stage process, outlined below, must be closely monitored. Please implement ways to monitor submissions and reconcile errors with electronic transmissions during these stages. If you work with an EDI vendor, clearinghouse or billing agency, it s your responsibility to ensure reports are accurate, flexible, clear and easy to understand. Additionally, please ensure your office staff gets appropriate training on report functions. Stage 1: EDI Reconciliation Provider s Office/Facility to EDI Vendor Reconciles provider submissions with that of the EDI vendor Displays claims originally submitted electronically that the EDI vendor switched to a paper submission Identifies claims that failed EDI vendor edits Provides required information (such as patient and claim detail) to correct and resubmit claims Balances total number claims and total dollars received Indicates the date claims were sent to each payer Stage 2: EDI Reconciliation EDI Vendor to Payer Reconciles the EDI vendor s submission with the payer Identifies the number of claims accepted or rejected by the payer along with the date received Provides required information (such as patient and claim detail) to correct and resubmit claims with errors Report basics Work reports each day, ensuring prompt handling of claims Reconcile both claim totals and dollars Correct claims with errors and resubmit them electronically to provide an audit trail and to avoid payment delays Work with EDI vendors to ensure Empire reports are available. Our reports are your receipt that claims were either accepted for processing or rejected due to errors. If you use an EDI vendor, you should work with them directly if there are questions about data content, delivery time frames, formatting or errors Help Desk 866-889-7322 98
If you need to contact us about reports 1. Identify the report in question. 2. Include the EDI vendor s name providing reports on your behalf, if applicable. 3. Provide claim submission date, claim detail and error message(s) returned. NOTE: We are not familiar with the proprietary reports generated by every EDI vendor. Please be prepared to provide details from our reports when you speak with an Empire representative. Questions to ask EDI vendors Occasionally, a vendor may switch to paper submissions for different reasons. Make sure your vendor is transmitting all of your claims electronically. Are the payer-specific report(s) reformatted by the EDI vendor? Are the payer s original reports available for reference if needed? If the payer s report is reformatted, does the EDI vendor omit or change any information found on the payer s original reports? What reports, if any, are available to reconcile EDI submissions at the EDI vendor and payer levels? Who is the contact if questions arise about EDI vendor reports? What is the estimated response time for resolution to EDI vendor report questions? Are there payer errors that only the EDI vendor can correct? If so, how quickly are the errors corrected and claims resubmitted? What is the notification process when submission delays occur? Is the EDI vendor automatically switching to a paper submission when claims error? What is the cost to switch to a paper submission? Are the paper claims being corrected before mailing? Does the vendor provide access to payer reports that are proof of receipt for timely filing? Helpful information for providers To speed claim payments, you should request and review reports in order to reconcile your electronic submissions and identify claims in error. A rejection on any level may impact the entire claims submission and certainly cash flow. Empire produces four separate reports, identifying the claim s acceptance or rejection status. Our timely delivery of reports helps you correct claim errors, often without missing a remittance cycle. Empire contracts with each of our EDI vendors, ensuring reports are delivered accurately, timely and according to specifications. It s your responsibility to ensure that the contract you have negotiated with your EDI vendor provides quality service and prompt delivery of payer reports, as appropriate. Please see the next page for a description and delivery schedule of each report. 10 9 Help Desk 866-889-7322
Report Description Empire contact Interchange Acknowledgement TA1 999 Interchange Acknowledgement 277CA Claims Acknowledgement Level 2 Status Report X12 Level 2 HIPAA Compliance Alert messages Generated when the electronic file structure and/or data contained within the file is invalid or corrupted. With invalid or corrupted information Empire is unable to open, identify or read the electronic file submission. Errors identified will cause the entire file to reject. Delivery Schedule Daily: Report generates only when a file error is detected Report confirms our initial acceptance and/or rejection of claim files you ve submitted to us. Empire validates the files we receive to ensure the file is addressed appropriately and its contents are valid based on file structure and submission requirements mandated by the Health Insurance Portability and Accountability Act or HIPAA. Errors identified on this HIPAA report cause the entire file to reject. X12 HIPAA Health Care Claim Acknowledgement is the business level acknowledgement for health care claims-837. Report returns a reply of Accepted or Not Accepted status based on the electronic claim Technical Report 3 and front end edits. For claims Not Accepted, the 277CA will detail additional actions required of the submitter in order to correct and resubmit. Errors identified at this level will cause individual claims to reject. Delivery Schedule Daily: Report generates acknowledging the acceptance or non-acceptance of a claim Proprietary report that validates code sets, data structure and balancing based on HIPAA file structure and submission requirements. The report also provides a summary detail for total claims(s) and charges(s) submitted, passed and failed. Errors identified will cause individual claims to reject. The level 2 Status report also edits claim information for validity, compatibility and formatting based on Empire business requirements. Errors at this level will cause individual claims to reject. Delivery Schedule Daily: Report generates displaying all claims passing Important electronic messages such as system modifications, submission tips and other Empire communications Delivery Schedule As needed. It is imperative that providers review Alert messages; they often require important action from the provider. Call EDI specialist at 866-889-7322 Call EDI specialist at 866-889-7322 Call EDI Specialist at 866-889-7322 Call EDI specialist at 866-889-7322 Call EDI Specialist at 866-889-7322 Access Empire EDI Solutions EDI User Guide Acknowledgements and Reports EDI User Guide Acknowledgements and Reports EDI User Guide Acknowledgements and Reports EDI User Guide Acknowledgements and Reports EDI User Guide Acknowledgements and Reports. If you are not receiving Alert Messages, contact your EDI Vendor. Help Desk 866-889-7322 10 11
Find more details at www.empireblue.com/edi You can find report descriptions, along with formatting specifications, error listings and troubleshooting tips online at empireblue.com/edi Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.