EDI setup for claims, RAs & more
The Centers for Medicare & Medicaid Services (CMS) mandates that all health care providers and payers must use the HIPAA 5010 electronic data interchange (EDI) formats to exchange EDI transactional business data.
File types available for electronic data interchange
We process files in ANSI X12 5010A1 (HIPAA-compliant) format.
- 270, Eligibility requests
- 271, Eligibility request responses
- 276, Claim status requests
- 277, Claim status request responses
- 277CA, Claim acknowledgment
- 278, Referrals and authorizations
- 834, Group enrollment
- 835, Payments, remittance advice
- 837, Claims
- 999, Functional acknowledgements
You can submit eligibility and claim status transactions in real time 24/7, and you'll receive the response in real time.
Exceptions to real-time availability:
- Regularly scheduled maintenance periods on the second weekend of each month. (Not all maintenance periods require downtime.)
- Non-routine downtime periods are published a week in advance.
- Unscheduled downtime is published within an hour directly to clearinghouses and/or trading partners who utilize real time services via a direct connection.
Priority Health does not publish companion guides as we adhere strictly to HIPAA standards as published in TR3 documents. TR3 implementation guides are available from X12 or Washington Publishing.
5010 requirements for claims
- A unique contract number for each member in the 2000B loop, as if the patient were the subscriber
- Street (not PO box) address for the billing provider
- Pay-to address is required when different from the billing provider's address
- 9-digit ZIP Codes for billing and servicing provider loops
- ZIP Codes for ambulance pick-up and drop-off locations
- National Provider Identifier (NPI) numbers, with subpart use
ICD-10 codes are supported.
- Loop 2010AA, code as a Type 1 for individuals/sole proprietors (bill with individual provider name, last name first, and NPI; loop 2310B is not required);
- Other statuses, code as a Type 2 (bill with a group name and Type 2 NPI, loop 2310B is required with rendering provider's name and Type 1 NPI). Rendering provider's name must match the Type 1 NPI billed. For details see National Provider ID information in this manual.
- Bill anesthesia services in minutes as opposed to units
- Use taxonomy codes
- Diagnosis code reporting must be separated
- Use ICD-10-CM and ICD-10-PCS qualifiers
Claim service receipts
Claim "service receipts" are communicated by email, fax or US mail, as selected by your office.
- They are sent directly to your office, usually the same day we receive a claim but no later than the next business day.
- They report the results of our up-front edits, including possible rejections for format and/or data.
- You may respond by correcting the claim and resubmitting it for processing.
Setting up your EDI connection
We accept EDI files via clearinghouses (preferred) or through a direct connection.
Direct connection transmission methods accepted:
- FTP w/PGP encryption and PGP signed (file transfer protocol with pretty good privacy)
- SFTP (secure file transfer protocol, also known as FTP over secure shell– no PGP encryption required)
- 3VPN (virtual private network)
Steps to set up HIPAA-compliant electronic (EDI) claim file submission
- Register an EDI account with us.
- Complete a service receipt form.
This form allows us to notify you directly that we have received your claims. It's very important to ensure that you are set up to receive this receipt so you can get the upfront edits and rejections as soon as possible.
Email the Priority Health EDI team at firstname.lastname@example.org, or call them at 800.942.0954, option 2.
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