Notes on EDI

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Electronic Data Interchange employs phone lines to transmit your claims to another computer.

 

Stratford has created a process to make EDI submission as smooth as possible.

 

The first step is the easiest. You create the appropriate claim form for the type of EDI you wish to submit. These can be either demanded individually or created from the Insurance Directory.

The next step requires you to enter the EDI directory and choose the correct intermediary (i.e., Medicare, Medicaid, private carrier, etc.). SSI® goes through a series of steps. First SSI® looks for an existing transmission file. If one is not found then a new one is created from the forms in your insurance directory. If forms are found, SSI® then pulls those forms over to the EDI directory and creates a new transmission file.

The third step does not require your participation. You just sit back and enjoy the background processing as your claims are transmitted.

Following transmission you will print your hard copy of the claims. The last step requires you to print the audit and clear the account. If the account is not cleared the next time you attempt to submit your EDI claims you will end up sending an old transmission file.

 

SSI® Note Some users choose to transmit all claims (i.e., private pay, Medicare, and Medicaid) to their clearinghouse. In this case the insurance form type may be the same for all electronically submitted claims.

 

Insurance Form Type

 

Your intermediary will determine what insurance form type you set for your Medicare clients

 

Intermediary                                Insurance Form Type        

Medicare:        all states ANSI 837        564        

Medicare:        All states NSF        514        

Medicare:        via a clearinghouse        511        

 

M6P964.DAT File

 

The associated file: M6P964.DAT (usually located in \ssiwin\4) holds the passwords and phone number used in transmission. This file potentially can have 30 lines.

 

CMS requires all Medicare submitters to change the password every 30 days. Your Medicare intermediary may not require this now, but someday it will. The Stratford program always creates a new password that can be used to automate the process of changing the password. We have implemented this for the payers that require it.

 

If your payer has notified you that you will need to change your password, you should immediately send a fax to Stratford so we can research it.

The Stratford program can create a new password that meets the CMS requirements, as we understand them:

• The new password must be different from the current password.
• The software vendor (Stratford) will not know what the password is.
• Medicare personnel will not know what the password is.
• The provider will always have access to the password using the EDI maintenance program.

 

M6R964.DAT File & Other .DAT File

 

M6R964.DAT is a text file used by the Medicare EDI program. All data stored in the M6R964.DAT file is labeled. EDI is controlled by various .DAT and .CTL files located in various directories. In your \ssiwin\4 directory you will find the M6P9xx.DAT file(s). The xx would be the transmission type, so that Medicare ANSI, which is usually numbered 964, would be controlled by the M6P964.DAT file.

 

Carrier EDI Setup

 

Common EDI Mistakes

 

The four most common reasons why Medicare claims do not transmit are:

 

1.        PIN or group number is missing in box 33 of the CMS 1500

2.        Charges on the claim form are $0.00

3.        The "M6R914.DAT" file has certain procedure codes excluded.

4.        The word "MEDICARE" is not in the insurance company name or is not in caps.

 

If you have a network you must transmit your claims from the workstation that has the modem attached.

 

Electronic Data Interchange requires that your data be perfect. There will not be a person examining the claims you submit to "interpret" what you meant. The following are some examples of the kind of mistakes to avoid. These are all mistakes made in the past year.

 

• When submitting Medi-Medi claims in California, assignment must be accepted.
• Do not submit procedure codes to Medicare that begin with the letter "X". There are many third-party coding seminars available. You should attend one per year to stay abreast of all the changes.
• California Medicaid (Medi-Cal) requires 14 digit ID #s. If you use the Social Security Format for California Medi-Cal ID numbers be sure to precede the SSN with "00000".
• Medicare requires the ordering physicians UPIN number for Lab services.
• California Medi-Cal will not transmit if the insurance company name is other than "MEDICAID" or "MEDI-CAL".
• California Medi-Cal will not transmit if no provider number shows on the insurance form. Check for the provider ID number. If missing, check the provider look-up file to be sure the number is in the file. Also check to be sure the "data control code" for Medi-Cal patients is set to 3.
• Private Carrier EDI requires that the provider number appear on the CMS 1500 form for the claim to be submitted electronically. Check the provider look-up file to be sure the number is entered correctly.
• Transamerica/Southern California Medicare will not transmit unless "Release of Medical Information" says yes.