Claims are electronically transmitted to the Medicare Contractor’s system in a standard format, which verifies claim data. This information is then electronically checked or edited for required information.
Claims that pass these edits, also called front-end or pre-pass edits, are processed in the claims processing system according to Medicare policies and guidelines. Claims with inadequate or incorrect information may:
• Be returned to the provider or supplier for correction;
• Suspend in the Contractor’s system for correction; or
• Have information corrected by the system (in some cases).
A confirmation or 997 acknowledgment report which indicates the number of claims accepted and the total dollar amount transmitted is generated to the provider or supplier. This report also indicates the claims that have been rejected and reason(s) for the rejection. Prior to resubmitting rejected batches, the acknowledgment report should be examined to determine the errors that occurred and the necessary corrections that should be made.
Original EDI files are available to the EDI Department for only 30 days. This is the raw data submitted in the ANSI format and can be accessed if a problem occurs or we need to help resolve a problem. It is important to ensure all reports are reviewed in a timely manner and steps are taken immediately to resolve any problems.
Benefits of EDI
• Improved cash flow – claims settle up to 50% faster
• 24-Hour claim transmission – send claims to Medicare 24 hours a day, 7 days a week
• Transmission security – a submitter ID and password are required to send claims
• Improved claim control – find and correct errors for immediate resubmission
• Reduced office costs – save time and storage space
• ANSI X12 4010A1 standardized industry format – Centers for Medicare and Medicaid (CMS), mandated standard for EDI transmission
