Allows health care professionals and facilities to send one transaction file for multiple patients to confirm basic eligibility. Depending on your software capabilities, eligibility responses automatically update your practice management system and/or can be printed.

Information included in response:

• Current eligibility dates
• Member demographic data
• Primary care information
• Copayment data
• Coinsurance data
• Deductible data
• Known Coordination of Benefit data

Enrollment Requirements: Completion of an EDI Transaction Enrollment Form

Allows health care professionals and facilities to verify claims status by sending one transaction file for multiple patients. Claims Status Inquiry is a useful diagnostic tool for billers who have a tight systematic reconciliation process or want to focus on complex claims.

Information included in response:

• HIPAA Claim Status and Category Codes
• Claim number if one is assigned

Enrollment Requirements: Completion of an EDI Transaction Enrollment Form

Initial response from that payer whether the claim is eligible for evaluation of processing and payment.

Enrollment Requirements: Enrollment is not required, will receive automatically.

If you currently enter/track referrals in your practice management software the 278 transaction will send your entire file to the health plan for processing. A response is returned that can automatically update your practice management system with referral numbers and date ranges, depending upon your system.

Medical and dental pre-certifications and pre-authorizations can also be sent electronically as one file. However, if your request mandates an X-ray or attachment these currently cannot be received electronically.

Information included in response:

• Referral number
• Date range
• Any referrals that cannot be processed are included in the referral response
• Tracking number is included for pre-certifications and pre-authorizations

Response time:

• Referrals 1-2 days
• Medical pre-certifications /pre-authorizations and dental pre-determinations have a response time in minutes to confirm the file was received. The final determination will be mailed to you.

Enrollment Requirements: Completion of an EDI Transaction Enrollment Form

Health Care Claim

• Professional
• Institutional
• Dental

This HIPAA compliant transaction allows you to submit your health care claims electronically and has many advantages over paper claim submissions. Your practice management software will generally edit your electronic claims for coding accuracy. Claims are then electronically sent to a clearinghouse that edits for syntactical X12 errors, and any coding and format concerns.

Enrollment Requirements: We do not require additional enrollment if you are enrolled with a claims clearinghouse (e.g., Office Ally, UHIN).

Learn more about electronic billing.

Health care professionals and facilities who use an Electronic Remittance Advice (ERA) can download their ERA and automatically have their practice management software quickly reconcile patient accounts. Most practice management systems then allow you to immediately generate and submit secondary 837 claim transactions as necessary. The process is entirely paperless.

We utilize HIPAA compliant American National Standard Institute (ANSI) Adjustment Reason Codes. Your software vendor can help you to integrate these universal adjustment reason codes and assist you with their interpretation. If needed, ANSI 835 Adjustment Reason Codes are available on the Internet at www.wpc-edi.com. ANSI Reason Codes are generic codes and may encompass a variety of adjustment/payment reasons.

Responses are sent in an ANSI 4010A format. Information included in the response:

• Basic claim identifiers
• Amount Paid
• Allowed Amount (except for Washington)
• Co-insurance amount
• Patient Responsibility

Enrollment Requirements: Enrollment with a clearinghouse, completion of an EDI Transaction Enrollment Form

Initial response from payer whether the claim is eligible for evaluation of processing and payment. Utah payers will either send 277 FE or 864 reports. 864 reports are also used by payers to send general correspondence that affect electronic transactions.

Enrollment Requirements: Enrollment is not required, will receive automatically.

Transactional acknowledgments 997/TA1 report receipt, acceptance and/or rejection of a batch. You receive a 997 transaction acknowledgement response from both the clearinghouse and the payor for any type of transaction you perform.

A 997 transaction reports syntactical errors against the HIPAA X12 standards and will also include payor specific edits. A 997 includes segments and data elements that were in error on the transaction. In addition, a 997 gives you batch details of how many claims/transactions were accepted, received and/or rejected in a batch and is not patient specific. A 997 transaction allows you to “map lost claims or transactions”.

A TA1 functional acknowledgement advises you of a complete transaction failure where nothing from the batch was accepted.

How to enroll: Submitters will receive this transaction automatically