Claims and Electronic Data Interchange (EDI) File...

Claims and Electronic Data Interchange (EDI) File Management

Availity Customer Connection 2011

©2011 Availity, LLC | All Rights Reserved 1

What We Will Cover Submit claims (837) to multiple health plans using one secure network and improve revenue cycle management with electronic remittance advice delivery (835). • 5010 Compliance • Claim submission overview • Web data entry claim submission • Electronic data interchange (EDI) batch file submission

2 ©2011 Availity, LLC | All Rights Reserved

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5010 Compliance Send and Receive 5010-Compliant Transactions • Visit www.availity.com/5010 • Up-convert and down-convert support • Testing with technology companies • Health plan readiness • 5010 Tips via e-mail

http://www.availity.com/5010�

Availity’s Claim Submission Methods

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Web Data Entry • Several participating health plans • Professional (CMS-1500) and

facility (UB-04) forms • Short forms and detailed forms • Front-end and HIPAA validation • Real-time claim adjudication • Customizable reporting

preferences

EDI Batch File • More than 1,300 health plans,

including commercial and government health plans

• Claim and non-claim transactions in one batch

• Submit and receive options • Batch- and transaction-level

validation including front-end and HIPAA validation

• Real-time claim adjudication • Customizable reporting

preferences

©2011 Availity, LLC | All Rights Reserved

Availity’s Health Plan List The Health Plan List is an informational document containing the EDI clearinghouse health plan list, NPI options, electronic remittance advice (ERA) list, and web solutions health plan list.

1. From www.availity.com click the Download Library link at the bottom of any page.

2. Click the Health Plans link.

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Partial Example

©2011 Availity, LLC | All Rights Reserved

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Web Data Entry Claim Submission

© Availity, LLC | All rights reserved. 8

Quickly submit a real-time, electronic claim or encounter.

Based on the paper-based CMS-1500 for professional claims and UB-04 for institutional claim forms.

Speeds up the claim review and adjudication process, helps prevent denials resulting from missing or incomplete information, and saves administrative costs and paper and mailing costs.

Provides added value to paper submitters, submitters who do not have a Practice Management System (PMS) or billing system, atypical providers who submit claims infrequently, and EDI submitters who need to submit a quick claim outside of the EDI process.

Users

Benefits

Forms

Overview

Web Data Entry Claim Submission Instead of submitting paper claims, enter claims individually online. Availity processes the claim for you electronically and delivers health plan claim responses to your organization’s ReceiveFiles mail box.

1. Click Claims Management | Professional Claim or Claims Management | Facility Claim.

2. Select the payer and transaction type. 3. Complete the required fields. 4. Click Submit. 5. Based on the health plan’s processing method, view the results.

Real-time claim adjudication – Results right on the screen. Batch processing – Confirmation of claim submission right on the

screen and additional results in your ReceiveFiles mail box. Also, use Claim Status Inquiry for real-time status.


Web 4010 Quick Claim Example


Partial example

Web 5010 Claim Example


Partial example

Viewing Web Claim Results • Payer that processes claims in real-time

• Humana processes claims and encounters submitted using Availity’s online forms in real-time.

• Payers that process claims in batches • All other payers currently process claims in batches. • For these payers, access the organization's ReceiveFiles mail

box later to view your claim results and look for text reports for each claim submitted.

• Specifically, look for reports ending in .ebt and .dpt file extensions.

• For every claim submitted, the organization receives three reports in both data and text versions.

• To reduce the number of reports in the box, the PAA can set reporting preferences to turn off unnecessary reports. See Availity Help to learn more.

© Availity, LLC | All rights reserved. 12

Web Claim Real-Time Adjudicated Results


5010 example

Web Claim Result – Batch Processing


4010 example

.ebt and .dpt Response Reports


Text Electronic Batch Report Partial Example

Text Delayed Payer Report Partial Example

Setting Up EDI Reporting Preferences

For organizations submitting claims or receiving 835 electronic remittance advice (ERAs) through Availity:

• Availity delivers EDI batch report files to your organization's ReceiveFiles mailbox that display various data about the EDI files and web entry batch-of-one claims your organization submits.

• PAAs use the EDI Reporting Preferences feature to specify the reports they want their users to receive, the file formats, and other reporting preferences.

• In the Availity menu, click EDI File Management | EDI Reporting Preferences. Select the check box or option button beside each item you want.

• For more information about each option, click Help at the top of any page. In the contents list, click PAA Tasks | EDI Set-up | Setting EDI Reporting Preferences.

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EDI Batch File Processing Upload batches of claims online or integrate with your organization’s practice management system or hospital information system to automate the claims process.

1. In your system, enter HIPAA-compliant claims and create an ASC x12 file.

2. Send (upload) the file to process through Availity’s clearinghouse. 3. Review responses. 4. Correct any rejected claims in your system and re-submit through

Availity.


Basic EDI Process


• Enter claims • Create and send

a batch file

• Conduct batch and transaction level validations

• Send accepted claims to payers

Submitter Availity Payer

• Review response files

• Correct and resubmit corrected claims

• Process transactions • Send responses

• Gather and format responses • Post response reports

acce

pted

rejected

Availity Response Overview

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File level validation Transaction level validation

Acknowledgements Within minutes; allow up to 4 hours

IBR Immediately after 997/999; allow up to 24 hours

EBRs Generally 24 to 48 hours after accepted claim sent to payer; allow up to 5 days

DPRs Varies

by payer

Although not pictured here, 277CA reports are also available.

EDI File Management Upload 1.Click EDI File Management | Send and Receive EDI Files. 2.Click SendFiles. 3.Click Browse, locate the file, and click Open. 4.Click Upload File.


EDI File Management Responses 1.Click EDI File Management | Send and Receive EDI Files. 2.Click ReceiveFiles. 3.Look for new files delivered since the last time you retrieved files

from the mail box. • For more information about file naming conventions, review the

Availity EDI Guide or Availity Help.


EDI Response File Examples View examples of responses and reports as Availity returns them:

1. Log into the Availity portal. 2. Click Availity Resources. 3. Click Reference. 4. Click EDI Guidelines. 5. Click EDI Guide. 6. View the PDF.

From www.availity.com: 1. Scroll to the bottom of the page. 2. Click on the Download Library link. 3. Click on the Availity EDI Guidelines link. 4. Click EDI Guide. 5. View the PDF.


Claim (837) Response Files (File Level)

Format and Extension

Response / Report Pipe

delimited Text ANSI x12

File Acknowledgement

(proprietary report)

.ACK .ACT

Interchange Acknowledgement .TAT (New 1.15.2011)

.TA1 (New 1.15.2011)

4010 Functional Group Acknowledgement .97T (Was - .ACT prior

1.15.2011)

.997 (Was - .ACK

ACT prior 1.15.2011)

5010 Implementation Acknowledgement .999 (New 1.15.2011)

Claim (837) Response Files (Claim Level)

Format and Extension Response / Report Response Information

Included Pipe

delimited Text ANSI x12

Immediate Batch Response

Invalid payer ID, HIPAA, and payer-specific front-end edits

.ibr .ibt

Electronic Batch Report Invalid payer ID, HIPAA, and payer-specific front-end edits, and payer responses

.ebr .ebt (Old - .TXT

prior to 1.15.2011)

Delayed Payer Report Payer responses .dpr .dpt

Navigating EDI Reporting Preferences In the Availity menu, click EDI File Management | EDI Reporting Preferences. If you are associated with more than one organization for this feature, select an organization.

On the EDI Reporting Preferences page, click the tabs to view, change, and save changes. Click the blue question marks for field-level help.

menu tabs

Thank you

Call 1.800.AVAILITY (282.4548)

Or visit us online at www.availity.com


http://www.availity.com/�

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