Signing Up for EDI

The SSI® program contains the EDI modules. They are integrated into the programs and do not need to be added or loaded. You must sign up with the intermediary or clearinghouse before you may start submitting, unless you are already an approved submitter. The procedures for filing your application differ for each EDI destination and your location. The text/examples below describe one area, Northern California. The procedures are similar for Wisconsin, Texas, New York, Florida, etc. We chose California because it has different intermediaries for Northern and Southern California physician billing. It has a different one for facility billing. There is another one for DME billing. Dental is different from all the others. Most states are much simpler.

Most EDI destinations require users to complete a testing period before allowing them to submit claims for payment. This testing period is used to check many things.

Certain specialties and procedure codes may require additional information to be included. EDI requires you to be more accurate. The benefits are quicker payment and fewer rejections.

After you have sent in the EDI applications, that payer will usually contact you within two weeks. If you do not hear from the payer, contact them. Once the application is accepted you will be assigned passwords. Contact Stratford once you have your passwords. Stratford will build the files that allow you to transmit. You may be asked to send a backup of your data to Stratford to facilitate testing.

Private carrier testing takes about a week to pass. Medicare and Medicaid can take 2-4 weeks, depending on how many tests need to be sent. Medicare will contact you with the results of each test. Medicaid must be contacted for the results of any test. It is important that you fax Stratford with the results of each test. If you do not hear from Medicare within two weeks of the test, please give Stratford a call and we will try to help you solve the problem.

Medicare Application

The application for physician's Medicare EDI in Northern California currently is available from NHIC, the Medicare intermediary. Once you receive your ID and password from Medicare, contact Stratford and we can arrange to start testing. The intermediary will never pay you for the test claims, so you must submit those test claims on paper. Once the Medicare intermediary has accepted your test claims, you may start sending your claims electronically for payment.

SSI® Note: Medicare has accepted a standard format named ANSI 837. This format promises to be even more "standard" than the National Standard Format. This format is included with the Stratford program. In addition to the ANSI 837 there is the ANSI 835, an electronic EOB form. This format file is recognized by the Stratford program and is automatically formatted for "humans" to read if you try to print it. Without the Stratford program or another program that can interpret the file, there would be no way to make any sense out of it. This will allow the Stratford program to automatically post payments to your files

Medicaid Application

To submit electronically, you must send an application to get a password and submitter ID number. The application form is available from your Medicaid representative. Your system already has the software to submit your claims to Medicaid. There is a test series of claims that must be sent. Once you have sent the required number of claims and the intermediary has accepted the test claims, you may then submit all of your Medicaid claims electronically.

Commercial Carriers and Health Maintenance Organization

Most of the commercial carriers (Blue Cross, Blue Shield, Aetna, etc.) accept claims electronically, but they may not accept the claims directly from the provider. Instead, they employ clearinghouses to review your claims for accuracy. After review, the clearinghouse forwards them to the correct carrier.

The clearinghouse handles claims for many different payers. They have a per claim charge but in many cases the fees are picked up by the individual insurance carriers.