EDI FAQ

Frequently Asked Questions about EDI

BMC HealthNet Plan takes electronic claims in the HIPAA-compliant X12N 837 version 4010 formats. Currently over 85% of claims are submitted to us electronically. We have active relationships with four of the largest clearinghouses in America and can also take electronic claims directly or via NEHEN.

Answers to the following questions are below:

1. Why should providers submit claims electronically?
2. Who can submit electronic claims to BMC HealthNet Plan?
3. What clearinghouses does the Plan work with?
4. What is a billing agency?
5. What is an 837 file?
6. How can providers send electronic claims to the Plan?
7. How can providers submit electronic claims directly to the Plan?
8. What is the Plan doing to accommodate 5010 transactions?
9. Why are a provider’s claims being rejected?
10. Can providers check members’ eligibility electronically?
11. Can providers tell if the Plan accepted the claims they submitted?
12. How can I check the status of a claim?
13. Can providers submit corrected claims electronically?
14. Do providers have to send claims electronically to the Plan?
15. How can providers get Electronic Remittance Advices (835s)?
16. How can providers get more information about EDI/electronic claims submission?

Why should providers submit claims electronically?

When you submit claims electronically, you will:

• streamline administrative tasks;
• save time and money because electronic (EDI) claims process faster and more accurately than paper claims;
• may be able to receive an 835 (electronic) remittance advice from us should you be set up properly, and choose to do so.

Who can submit electronic claims to BMC HealthNet Plan?

Participating and non-participating providers can send claims to BMC HealthNet Plan electronically if they meet any one of the following criteria:

• They can produce claims in HIPAA-compliant 837 format.
• They use a billing agency that can produce HIPAA-compliant 837 files.
• They use one of the clearinghouses listed below (or a clearinghouse or billing agency that uses one of the clearinghouses listed below).
• They submit claims via the New England Healthcare EDI Network (NEHEN).

If a provider already sends electronic claims to another insurance plan, chances are that the provider can also send claims to BMC HealthNet Plan. At this time BMC HealthNet Plan does not have functionality on its website to accept claims or issue claims submission software for provider use.

NOTE: The provider’s NPI must be on file at BMC HealthNet Plan. Claims submitted with NPIs that are not registered at BMC HealthNet Plan will be rejected. If a non-participating provider or a new doctor at a participating provider practice has an NPI that is not registered at BMC HealthNet Plan, that provider should contact his or her assigned Provider Relations representative, call our provider line at 1-888-566-0008 to register the NPI, or click here to submit the NPI information directly.

What clearinghouses does BMC HealthNet Plan work with?

A clearinghouse is a company that takes claims information from any doctor, hospital, etc., and sends claims on their behalf to “payers” (e.g., insurance companies like Blue Cross Blue Shield) on paper or as electronic files. Large clearinghouses have many subsidiaries, usually billing or claims companies that they have bought. For instance, Emdeon (formerly known as WebMD) bought Envoy, which used to be the biggest clearinghouse. Emdeon also bought Medical Manager, a company that produces software many doctors use to send electronic claims. We now have active relationships with six of the largest clearinghouses in America: Emdeon (also known as WebMD, NEIC, Envoy, HealthWire, Medical Manager, and by other names), The SSI Group, Capario (formerly known as MedAvant, ProxyMed, MedUnite and NDC), RelayHealth (comprising McKesson and Per-Se), Gateway EDI, and Allscripts/Payerpath.

Most other clearinghouses have relationships with one of these clearinghouses, so even if a provider office does not work directly with one of the above, BMC HealthNet Plan should still be able to receive electronic claims through your relationship with that other clearinghouse.

What is a billing agency?

Basically, billing agencies are “middle men” between providers (e.g., doctors/facilities) and clearinghouses and/or payers. Billing agencies create claims for providers using the information the provider sends to them. Billing agencies often give providers software to use to send the claims information to them. Many billing agencies then send paper or electronic claims to clearinghouses, although some send claims directly to payers (e.g., insurance companies).

What is an 837 file?

An 837 is a certain kind of electronic claims file that HIPAA requires providers to use to submit claims electronically. There are some older forms of the 837 file, but HIPAA requires that health plans and EDI submitters use the latest version, called “X12N 837 version 4010.” (The newest standard, 5010, is mandated for use in January 2012; see Question 8 below for more information.) There are very specific rules about what kind of information can go in an 837 and exactly where that information should be put. Doctors who bill using the paper CMS-1500 form would use an 837P (the P is for professional) format; hospitals and facilities that use the paper UB-04 form would use an 837I (the I is for Institutional). Most doctors can’t produce 837 files directly, so if they want to send electronic claims, they must use a clearinghouse or billing agency that can produce the 837 files for them. The current HIPAA-compliant 837 form used to be known as the “Addenda version” and has these numerical designations:

How can providers send electronic claims to BMC HealthNet Plan?

There are several alternatives for submitting claims to the Plan:

Providers can send claims directly to BMC HealthNet Plan. If a provider produces claims in an 837 format or uses a billing agency that can produce claims in an 837 format, the Plan can receive those files directly (see Question 7). This will probably be the most cost-effective way to submit claims to the Plan since clearinghouses tend to charge fees that vary based on the number of claims submitted on a provider’s behalf.

Providers can send claims through NEHEN and NEHENNet to BMC HealthNet Plan. NEHEN subscribers should contact their NEHEN Technical Support representative to request setup.

Providers can submit claims to BMC HealthNet Plan through a clearinghouse or billing agency. The SSI Group, Capario, Emdeon, RelayHealth, Gateway EDI, Allscripts/Payerpath or one of their subsidiaries can send claims files in the required HIPAA-compliant 837 format to BMC HealthNet Plan on a provider’s behalf; billing agencies offer the same service. To get set up, providers should contact their representative at the clearinghouse or billing agency for instructions. BMC HealthNet Plan’s payer IDs for each clearinghouse are listed in Question 3.

At this time BMC HealthNet Plan does not have functionality on its Web site to accept claims or issue claims submission software for provider use.

How can providers submit electronic claims directly to BMC HealthNet Plan?

BMC HealthNet Plan can receive electronic claims directly from a provider or the provider’s billing agency, instead of via a clearinghouse, and this method should be less costly for the provider since clearinghouse fees tend to vary based on the number of claims processed on a provider’s behalf, and because the Plan charges no fees for direct submission. To send claims directly to the Plan, the provider or its billing agency must be able to produce a HIPAA-compliant 837 file, have an Internet connection (to transmit the claims files), and have either Secure FTP software (e.g., FileZilla) or PGP encryption software to satisfy HIPAA Privacy/Security regulations. Providers or billing agencies interested in submitting claims directly to BMC HealthNet Plan should contact us at 617-748-6175; our EDI Claims Companion Guide is also available online (click “Companion Guide” on the left under “EDI Information”). At this time BMC HealthNet Plan does not have functionality on its Web site to accept claims or issue claims submission software for provider use.

What is the Plan doing to accommodate 5010 transactions?

The federal government mandates that all electronic health care transactions conform to the new 5010 standards as of January 12, 2012. BMC HealthNet Plan is actively working to accommodate these new file formats and will be ready to process claims (837), electronic remittance advices (835), and eligibility requests (270/271) by the deadline. Companion Guides will be available in September 2011, but at this time the Plan is not requiring any new data offered by the 5010 transactions. Providers/EDI submitters wishing to test 5010 transactions or to get more info can contact us at 617-748-6175.

Why are a provider’s claims being rejected?

BMC HealthNet Plan rejects initial claims submissions only for three reasons: unrecognized member IDs, unrecognized NPIs (i.e., mis-typed NPIs or NPIs not registered at BMC HealthNet Plan), or a pay-to tax ID that doesn’t match the pay-to tax ID BMC HealthNet Plan has on file for the submitted NPI. For electronic claims, those IDs/NPIs must be in certain locations in the 837 files with certain qualifiers. We often find that a provider’s software shows the correct IDs/NPIs on the screen, but the 837 file that we receive from the clearinghouse has the IDs/NPIs in the wrong location or with the wrong qualifier. For corrected claims (see Question 13 below), there are additional criteria that must be satisfied to prevent a claim from rejecting.

Can providers check members’ eligibility electronically?

There are two electronic ways for providers to check whether a member is eligible for services at BMC HealthNet Plan:

• Using BMC HealthNet Plan’s Web Services (login required).
• Using the HIPAA standard 270/271 transactions through any of the following partners: NEHEN, Gateway EDI, Passport Health, TransUnion (formerly MedData) and HDX/Siemens

To read about the other services we offer on our website and how to sign up, see Question 12.

Can providers tell if BMC HealthNet Plan accepted the claims they submitted?

After receipt of an electronic claims file, BMC HealthNet Plan provides an Initial Claim Status report (sometimes referred to as a scrubber or error report) the next business day. This report shows whether each claim was accepted for processing or rejected. The only time an initial electronic claim will not make it into the Plan’s system is if the provider has used an unrecognized NPI, an unrecognized member ID, or a pay-to tax ID that doesn’t match the pay-to tax ID BMC HealthNet Plan has on file for the submitted NPI. Providers can also check on the status of claims they’ve submitted by logging into the Plan’s website (if they’re participating providers) or calling our provider line at 1-888-566-0008. Providers who don’t have a login to the Plan’s website should contact their Provider Relations representative or call the provider line at 1-888-566-0008 to obtain one. All providers sending electronic claims MUST submit with the claim an NPI that is registered at BMC HealthNet Plan AND a valid member ID or the claim will reject from our system.

How can I check the status of a claim?

You can check the status of a claim 24 hours a day, seven days a week using the secure claims status inquiry interactive tool that is part of the Plan’s Provider Web Services. If you don’t already have a login, contact your provider relations representative or call the provider line at 1-888-566-0008.

In addition to determining the status of a claim, you can streamline your administrative tasks by using BMC HealthNet Plan’s Web services to:

• run online reports such as member panel and redetermination reports;
• verify member eligibility; and
• look up policy and code information.

Can providers submit corrected claims electronically?

Providers can submit corrected claims electronically using the 837 format, but there are very specific rules for doing so, i.e., required by the 837 format, and outlined in our EDI Claims Companion Guide on pages 15 and 16. Basically, corrected claims are submitted electronically as “replacement claims,” which have frequency codes of 7. UB-04 submitters are familiar with frequency codes from Form Locator 4, but frequency codes are new to CMS-1500 submitters with the introduction of the 837P electronic file. A replacement claim asks the insurance company to take a specified claim received earlier and replace it with newly submitted information. Corrected claims must meet additional criteria to be accepted: they must include an original BMC HealthNet Plan claim number in a finalized status, and the member ID and NPI must be the same on the corrected claim and the original claim.

Here’s a simplified example:

• A provider sends a claim to BMC HealthNet Plan in January with three line items and a total charge of $250.
• BMC HealthNet Plan gives the claim an ID of E00306842700 and pays the provider $250.
• In February the provider realizes the claim should have had five line items and a total charge of $400.
• The provider submits an electronic claim with a frequency code of 7, referencing the original claim ID of E00306842700, and showing all five line items (not just the two new line items).
• BMC HealthNet Plan processes the replacement claim, assigns a new ID of E00306842701 and pays the claim.

Do providers have to send claims electronically to BMC HealthNet Plan?

No. Providers can still send paper claims. However, submitting claims electronically allows for faster turnaround of and greater accuracy in claims payment. Also, if a provider is billing for a service that requires an invoice or attachment (e.g., durable medical equipment, COB claims), those claims should not be sent electronically. Please note that paper claims will also be rejected without an NPI registered at BMC HealthNet Plan.

How can providers get Electronic Remittance Advices (835s)?

Providers who submit electronic claims directly to BMC HealthNet Plan can get electronic remittance advices, also known as 835s, which is the HIPAA name for the electronic file. (Providers who use The SSI Group, RelayHealth, Gateway EDI, or Allscripts clearinghouses can also get 835s; some billing agencies can also return 835s to their submitters.) Providers submitting claims to the Plan through NEHEN can get an 835 for those claims through NEHEN. Our 835s (4010 version) do not include any information on paper claims or claims submitted via different sources (see our 835 Companion Guide for more Plan-specific 835 notes). Therefore, in addition to electronic remittance advices for electronic submitters, paper remittance advices are sent to any providers receiving payments; PDF versions of the paper remittance advices are also available on the Plan’s website. Paper remittance advices include information on claims submitted both electronically and on paper. Providers who submit electronic claims directly to us and who want to get 835s should contact us at 617-748-6175. Providers who do not wish to receive the paper remittances can contact their Plan provider representative or call 617-748-6175.

How can providers get more information about EDI/electronic claims submission?

Providers can download a copy of our EDI Claims Companion Guide, which outlines our testing procedures and communications setup and gives Plan-specific information about creating 837 format files. The guide has general billing/EDI claims information and some very specific technical sections. Providers can also call us at 617-748-6175.