EDI Guidelines

What is EDI

Here i have listed most and common errors in the EDI form when you filled up. So please have this remembered and fill up the form accordingly.

Electronic Data Interchange (EDI)

Providers can decrease paperwork and increase operating efficiency with Electronic Data Interchange (EDI). EDI is the fastest, most efficient way to exchange eligibility information, payment information and claims. Blue Cross’ experienced EDI staff is ready to assist in determining the best electronic solution for your needs.

Electronic Claim Submissions

The Plan accepts electronic claim submissions through Electronic Data Interchange (EDI).

Advantages of EDI

* Submitting claims electronically is less costly than billing with paper.

* In most instances, the Plan can process your electronic claim in half the time of a paper claim.

* Clearinghouses charge varying fees. The Plan has free options, including connectivity and  software that are free. Contact the EDI department to see if you qualify for this service.

You may also contact your clearinghouse or billing software vendor to see if they offer free options.

There are seven primary clearinghouses through which we receive EDI transactions. Those companies are:

* ACS EDI Gateway Inc.

* Availity

* Emdeon

* Legacy Consulting

* RelayHealth (McKesson)

* SSI Group Inc.

* ZirMed

Because most clearinghouses can exchange data with one another, providers should work with their existing clearinghouse, if different from those listed, to establish EDI with the Plan.

All files submitted to the Plan must be in the ANSI ASC X12N format, version 4010A. Implementation guides for HIPAA transaction sets are available at http://www.wpc-edi.com.

Missing, invalid, or unauthorized signature, title, and/or date

Verify that all forms are signed by an authorized official. Always include a date and title with your signature.

Missing required information

Complete the forms in their entirety. Incomplete forms are returned.

Missing or incorrect Highmark Medicare Services Provider Transaction Access Number (PTAN)

Ensure the Provider Transaction Access Number (PTAN) is reported in the required field. The PTAN is the same as your Provider Identification Number (PIN) that you used for billing prior to being required to report a National Provider Identifier (NPI).

Illegible form

Avoid faxing enrollment forms. Forms received via fax are often illegible which results in returned forms. If you must fax your forms, please do not also mail the form. If legible, faxed forms will be processed.

Missing or invalid address

Ensure the practice address indicated is the address Medicare has on file. The address Medicare has on file is the address used when completing the 855 form and enrolling with the Medicare program.

Missing or incorrect NPI of provider, group, physician, or supplier

Ensure the NPI is reported in the required field in addition to your PTAN.

Missing or incorrect name of provider, group, physician, or supplier

Ensure the provider name on the EDI forms matches the provider name that Medicare has on file. The name Medicare has on file is the name used when completing the 855 form and enrolling with the Medicare program.

Invalid Submitter Number

Ensure the Submitter ID is correct when requesting to be linked to an existing Submitter ID. If unsure of the correct Submitter ID contact the billing service or clearinghouse for verification. (NOTE: If the billing service or clearinghouse does not have a Submitter ID, they must obtain one prior to linking a provider.)

The software vendor, billing service and clearinghouse needs to complete an EDI Agreement form and EDI Setup Requirements form prior to processing this form

If you are a software vendor, billing service, or clearinghouse who is requesting a Submitter ID, please complete a Vendor Agreement form (8291) PRIOR to completing forms to enroll a provider with you.

Invalid forms

Ensure the most current EDI forms are being used. Outdated forms will be returned. To obtain the most current forms please visit our Web site.


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