Electronic Data Interchange (EDI) for Medical and Hospital Claims

Electronic Data Interchange (EDI) for Medical and Hospital Claims
The Plan encourages all providers to submit claims electronically. Providers/practitioners may contact the EDI Technical Support Hotline at (877) 234-4275 or email with questions.

Advantages of Electronic Submission
Electronic data interchange (EDI) allows faster, more efficient, and cost-effective claim submission for providers. EDI, performed in accordance with nationally recognized standards, supports the health care industry’s efforts to reduce administrative costs. The benefits of billing electronically include:

  • Reduction of overhead and administrative costs. EDI eliminates the need for paper claim submission. It has also been proven to reduce claim rework (adjustments).
  • Receipt of reports as proof of claim receipt. This makes it easier to track the status of claims.
  • Faster transaction time for claims submitted electronically. An EDI claim averages about 24 to 48 hours from the time it is sent to the time it is received. This enables providers to easily track their claims.
  • Validation of data elements on the claim form. By the time a claim is successfully received electronically, information needed for processing is present. This reduces the chance of data entry errors that may occur with the use of paper claim forms.
  • Quicker claim completion. Claims that do not need additional investigation are generally processed quicker. Reports have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt.

NOTE: All the requirements for paper claim filing apply to electronic claim filing.

Hardware/Software Requirements

There are many different products that can be used to bill electronically. As long as you have the capability to send EDI claims to Emdeon, whether through direct submission or through another clearinghouse/vendor, you can submit claims electronically.
Emdeon is the largest clearinghouse for EDI health care transactions in the world. It has the capability to accept electronic data from numerous providers in several standardized EDI formats and then forward accepted information to carriers in an agreed upon format.

Contracting with Emdeon and Other Electronic Vendors

If you are a provider interested in submitting claims electronically to the Plan but do not currently have Emdeon EDI capabilities, you can contact the Emdeon Sales Department at (800) 366-5716. You may also choose to contract with another EDI clearinghouse or vendor who already has Emdeon capabilities.

NOTE: Providers can contact the EDI Technical Support Group to obtain names of other EDI clearinghouses and vendors.
Contacting the EDI Technical Support Group.

After the registration process is completed and you have received all of your certification material, proceed as follows:

  • Read the instructions within the Provider Manual, Section 18.2 carefully with special attention to the information on exclusions, limitations, and especially, the rejection notification reports.
  • Contact your system vendor and/or Emdeon to inform them you wish to initiate electronic submission to the Plan.
  • Be prepared to inform the vendor of the Plan’s electronic payer identification number. The Plan’s number is 61129.
    Specific Data Record Requirements

Claims transmitted electronically must contain all the same data elements identified within the “Claim Filing” section of Passport Health Plan’s Provider Manual. Emdeon or any other EDI clearinghouse or vendor may require additional data record requirements.

Electronic Claim Flow Description
To be sent electronically to the Plan, all EDI claims must first be forwarded to Emdeon. This can be completed via a direct submission or through another EDI clearinghouse or vendor.

Once Emdeon receives the transmitted claims, they validate the claims against Emdeon’s proprietary specifications and Plan specific requirements. Claims not meeting the requirements are immediately rejected and sent back to the sender via a Emdeon error report. The name of this report can vary based upon the provider’s contract with its intermediate EDI vendor or Emdeon.

Accepted claims are passed to the Plan, and Emdeon returns an acceptance report to the sender immediately. Claims forwarded to the Plan by Emdeon are immediately validated for provider identification number requirements. Claims that do not meet this requirement are rejected and sent back to Emdeon, who also forwards this rejection to its trading partner – the intermediate EDI vendor or provider.

Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from Emdeon or other contracted vendors must be reviewed and validated against transmittal records daily.

NOTE: Contact EDI Technical Support at (877) 234-4275 for a detailed list of Emdeon data requirements.

IMPORTANT: Emdeon will only send a functional acknowledgement* to its trading partner whether it is the EDI vendor or provider. Providers using clearinghouses and vendors other than Emdeon are responsible for arranging to have these reports forwarded to the appropriate billing or open receivable departments.

* A functional acknowledgement is a report verifying acceptance or rejection of each claim in a transaction set (a transmitted group of claims).

Claims containing valid provider identification numbers are also validated against member eligibility records before acceptance by the Plan. If a patient cannot be identified as a member of the Plan, a denial letter will be forwarded directly to the provider. This letter is sent to the payment address documented in the Plan’s provider file. Claims passing eligibility requirements are then passed to the claim processing queues. Claims are not considered as received under timely filing guidelines if rejected for missing or invalid member data.

EDI Frequently Asked Questions

EDI Frequently Asked Questions

What is the position of the Rendering Provider Network ID field?

According to Envoy proprietary format the Rendering Provider Network ID is in the following location:

if filing for hospital charges (UB 92) – 46:12
if filling Medical charges (HCFA 1500) – E6:14

Must I enter Providers Id number in block 33?

Every software is different and mapped differently. Please contact your software vendor for the location.

How soon will you receive my claims?

We will receive claims within 24 to 48 hours from Emdeon.

When will I receive my payment?

Usually it takes approximately 2 weeks or less for the payment to be processed.

How do I begin to do EDI billing with your company?

In order to bill Passport Health Plan electronically you will need to contact your vendor and/or clearinghouse to request for our payer ID be added to your list of payers. This should be sufficient to get you started. If you have any questions or experiencing problems you can contact our Emdeon Provider Support Line at (800) 845-6592, or you can email us.

What is your Payer ID Number?

Our payer ID number is 61129.

I received a rejection report stating “Invalid Provider ID prevents Carrier from processing”. What does it mean?

This message is issued whenever Rendering Provider Network ID field on the electronic claim is populated with incorrect information. The field should only be populated with the Provider’s Individual ID number assigned by the Plan. Provider ID numbers maybe validated by contacting Provider Services at 800-578-0775.

Electronic Data Interchange (EDI) Process for Medical and Hospital Claims

View information about Medical and Hospital Claims EDI Process.