Electronic claim submission basic overview

INTRODUCTION TO ELECTRONIC DATA INTERCHANGE (EDI)

EDI is the process of transacting business electronically. It includes submitting claims electronically, or “paperless” claims processing, as well as electronic remittance, Electronic Funds Transfer (EFT) and electronic inquiry for claim status and patient eligibility.

What Are the Benefits of EDI?

The benefits of EDI are as follows:

• Medicare Part B claims process faster and providers are reimbursed sooner, improving their cash flow. Payment for electronic claims may be released after 13 days; payment for paper claims can be released after 29 days.

• Mailing and administrative costs are significantly reduced.

• Because of GPNet editing, fewer claims are returned with development letters, saving staff time and effort (refer to the GPNet Edits Manual on Medicare’s Web site at http://www.trailblazerhealth.com/Publications/Training%20Manual/GPNetEditManual.pdf in the “EDI Publication” section for a list of GPNet edits).

• Better control over filed claims. The data providers enter into their system is sent directly to Medicare’s claims processing system exactly the way they sent it; there is no need for intermediate data entry. A response report lets providers know that Medicare’s computer system has received their claims.

• The patient account number appears on every Explanation of Medicare Benefits providers receive, which reduces staff time spent locating payment-posting information.

• Providers can further automate their office using Electronic Remittance Advice (ERA) and EFT.

• Providers have access to online inquiry, which allows access to claims status and patient eligibility information. This information is obtained through dial-up capabilities using software that is provided at no cost and is compatible with their IBM or IBM-compatible PC.

• Providers receive ongoing customer support through Medicare’s EDI Technology Support Center.