Emdeon

EDI Tip Sheet

Claim Attachments

Note that many insurance companies have eliminated or significantly reduced the need for paper attachments for referrals, progress notes, ER visits, and more. Insurance payers prefer to receive your claims electronically.
Payers will request additional information when it is needed.
Refer to the Payer EDI Fact Sheets for specific exceptions and additional information.

Rejected Claims

Correct claims in your practice management system and resubmit them electronically if they are rejected due to invalid field information, coding, or patient information.
Direct questions regarding modification of claim data in your system to your contracted POMIS system vendor, or Emdeon if you use an Emdeon product.
Resolve rejected claims issues promptly. Some rejections may pertain to system set up that can easily be addressed.
Request a monthly report of common rejections from your vendor and follow up to resolve rejections quickly

Carrier Tables, Payer ID Set-Up, Re-Bills

Check to see that the payer tables in your computer system are set to generate electronic claims vs. paper claims.
Confirm that Payers with multiple street addresses have the same electronic Payer ID.
Make sure the payer spelling and setup are consistent and set as electronic vs. paper.
Confirm that new patient records and additional payer listings created by front desk staff are set to be sent electronically.
Make sure you set your re-submissions / re-bills to be sent electronically. Most systems have automatic claim re-bill capabilities that resend claims every 30-60 days if payment has not been posted.

Please Note: Contact your Physician Office Management Information System (POMIS) vendor before making any system changes or adjustments.

Submission Reports

Take time to review the clearinghouse and payer submission reports. Without verifying that your insurance claims were accepted, you put your receivables at risk. Most common errors which can be avoided by reading available reports include:

Missing or incorrect Provider ID or Member ID
Number of claims and dollar amounts for your batch does not match those accepted.

When a claim is rejected, either at Emdeon or at the insurance payer, correct the claim in your system and resubmit electronically.

Critical Information about Acknowledgement and Reject Reports

Claims filed electronically are not considered "received" by a health plan until they have passed system edits and have been accepted into the payers' claims processing system. For every claim filed electronically, the provider should monitor whether or not that claim has been rejected by reviewing EDI Acknowledgement and Reject reports on a regular basis. The following reports should be monitored regularly:

Initial Reject Report (Emdeon Report R022 or RPT 05 or equivalent vendor report) - This is a report that shows claims rejected by Emdeon because they have not met the initial clearinghouse criteria approved by the payer. These are claims that were not forwarded to the health insurance payer. Note: the most common errors include Provider ID and Member ID errors. Provider ID and Member ID may often be required, and Emdeon edits to ensure that, at a minimum, the format of these data elements is consistent with payer requirements. Claims appearing on this report should be corrected and re-submitted electronically as soon as possible to avoid timely filing issues.
Initial Accept Report (Emdeon Report R026 or RPT 04 or equivalent vendor report) - This is a report that shows Emdeon accepted the EDI claim and forwarded it to they health insurance payer for additional payer editing and processing. Please note that claims can pass clearinghouse edits, be displayed on the Initial Accept Report, but still be rejected by the payer.
Payer Reject Report (Emdeon Report R059 or RPT 11 or UCRR or equivalent vendor report) - This report states that the health insurance payer rejected the claim. A claim that is filed and rejected is not considered "received" by the payer. These claims should be corrected and re-submitted electronically as soon as possible to avoid timely filing issues.

While not all payers return Payer Reject Reports, if you are not receiving the above described clearinghouse and payer reports on a regular basis, please contact Emdeon Business Services immediately at 800-845-6592.

A provider can avoid timely filing issues through understanding and regular monitoring of EDI Reports. This process will help to ensure all rejected claims are re-filed timely and electronically. Regular monitoring of clearinghouse and payer reports will help you to stay in control of all your electronic billing.

If a provider wishes to dispute a timely filing denial of an EDI claim, many insurance payers accept a copy of the Initial Accept Report (Emdeon Report R026 or RPT 05) and/or Payer Reject Report (Emdeon Report R059 or RPT 10/11) from the clearinghouse showing that the payer initially accepted the claim for payer editing. Please check with individual payers to confirm which reports are acceptable proof of timely filing.

Other Tips

Confirm payer policies on handling secondary claims by checking the Payer EDI Fact Sheets or contacting the payer directly.
Always submit claims with the patient's name exactly as it appears on the ID card or in the payer's system. Submit a real time electronic eligibility inquiry to confirm.
Always submit claims with the patient's birth date exactly as it appears on the ID card or in the payer's system. Submit a real time electronic eligibility inquiry to confirm.
Ensure you are using a valid code for the date of service. Verify that the proper date format is being used. Contact your vendor to modify date formats.

Explanation Of Benefits

Contact the payer directly for questions regarding explanation of benefits.