EDI Helpful Hints and Troubleshooting Tips

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Situation Provider’s Responsibilities

Determining when to contact the EDI Vendor Vs Anthem EDI Helpdesk Vs Anthem Group Support.

1. Your EDI vendor is the first point of contact, as the vendor supports your software and submission capabilities and provides customer service for issues such as:

ü HIPAA filing requirements, file formatting and compliance.

ü Connectivity and delivery malfunctions with payers.

ü Internal editing or software questions.

ü Problems with interpretation or not receiving reports.

ü EDI report indicates there are vendor software errors not payer errors.

2. Contact an Anthem EDI specialist when you have questions about the electronic services Anthem provides. Contact Anthem toll free at (800) 991-7259. Select option 2 and then option 2 again.

Or, if you prefer, visit our Web site at www.anthem.com/edi – select "Virginia" for information on:

ü EDI enrollment and transaction file testing.

ü Anthem 837,835 and transactions filing specifications.

ü Electronic claims filing instructions, such as COB, PWK and notes.

ü Anthem reports and edits.

ü File delivery verification.

ü EFT and 835 payment advice enrollment and change request.

Contact an Anthem service operations representative when you have specific claims processing questions.

Richmond (804) 342-0010

Toll Free (800) 533-1120

 
 
 

Situation Provider’s Responsibilities

Filing claims using an-Anthem- assigned, active, six-digit provider number

Anthem assigns a unique six-digit provider number to identify a providers’ office and to make claims reimbursements.

ü File using an appropriate, six-digit ACTIVE Anthem provider number every time you submit a claim to Anthem, Virginia. Without a provider number, Anthem cannot process The claim.

ü Ensure that all claims information – including the provider number and payee indicators – are accurate, ask the EDI vendor how to avoid transposition of provider numbers or keying errors.

Note: When installing new software or upgrades always test with the vendor or clearinghouse ensuring the correct provider number and payee codes are assigned to your claims.

ü Notify the EDI vendor or internal programmers if assigned new Anthem provider numbers so that internal files can be updated accordingly.

ü Send Anthem EDI Specialist a written request to establish electronic EFT remit (835 Payment Advice) when new provider numbers have been assigned.

ü Contact Anthem if unsure of the Anthem-assigned provider number to use or when a provider number needs to be validated. Dial toll-free (800) 533-1120 (outside Richmond) or (804) 342-0010 (Richmond area), and select option 4 to reach provider Network Administration.

ü Refer to the Anthem Companion Guide for instructions and placement of the Anthem assigned six digit provider number within the electronic file. www.anthem.com/edi – select " Virginia"

 
 
 

Situation Provider’s Responsibilities

Submitting electronic claims with incorrect provider numbers and/or payment indicators incorrectly set to reimburse the patient.

STOP all electronic transmissions.

ü Notify your Electronic Data Interchange (EDI) vendor and the EDI Solutions immediately. (EDI vendors include clearinghouses, billing agencies and software vendors.)

ü Contact Anthem using a 151 Adjustment Request with the following information – Date of submission(s), incorrect and correct provider numbers, total number of claims involved.

ü Work with your EDI and/or Practice Management vendor (s) to determine where the incorrect indicators are being set, and make the appropriate system modifications.

ü Install editing at the office, or, if using an EDI and /or practice management vendor, request software changes to prevent future occurrences.

ü Resume electronic transmissions once issues are resolved.

ü Re-submit claims electronically with the corrected information or retrieve payments sent to members in error.

 
 

Situation Provider’s Responsibilities

Receiving appropriate payer notification of changes impacting electronic submission.

Anthem contracts with trading partners and provides a 45-day advance notice of all system modifications. Should you find that your EDI vendor is not forwarding notifications to you:

ü Request that your EDI vendor promptly retrieve Anthem alert messages when received, and convert the messages into a format that your internal office practice system can accept. Schedule routine delivery of these messages to your office.

ü View all electronic alert messages on Anthem’s Web site at www.anthem.com/edi. Select "Virginia" and "news bulletins."

 
 
 

Situation Provider’s Responsibilities

Requesting a "Payer ID’" in order to submit claims to Anthem.

ü EDI vendors – NOT Anthem – provide and maintain listings of payer ID numbers for routing transactions to the appropriate payer. This routing takes place between the EDI vendor and the provider’s practice management system. Your EDI vendor should provide the "Payer ID" for the provider.

 
 
 

Situation Provider’s Responsibilities

Accessing the Internet and Point of Care to submit electronically.

The Internet and Point of Care are helpful tools that help streamline administrative tasks within your office but are not required in order to submit electronically. Anthem, like many payers, has a Web site, www.anthem.com/edi, for posting pertinent information about electronic submission. Anthem Point of Care permits secure inquiry access to eligibility, membership and claim information.

 
 
 

Situation Provider’s Responsibilities

Reconciling electronic funds transfer (EFT).

ü Verify the remittance and electronic fund transfer (EFT) check amount (s) on Point of Care or electronic payment advice (ERA).

ü Anthem recommends the provider contact the bank, ensuring the correct EFT amount is posted

Note: Anthem posts monies directly to the providers bank accounts on Tuesday of each week by 9:00 a.m.

 
 

Situation Provider’s Responsibilities

Actions that will prevent electronic claim errors.

Working with internal programming staff and / or EDI vendor on the items below will help prevent electronic filing errors:

ü Install editing to ensure electronic claims are HIPAA-compliant.

ü Install edits that will validate information filed electronically (such as validate Anthem provider number, require three-position alpha prefix) and prevent keying errors.

ü Install payer front-end edits, allowing the provider to make the necessary corrections prior to submitting the claim. (See Anthem Companion Guide, Part II, Chapter 8 Front End Edits)

ü Maintain a current listing of code sets, ensuring codes submitted are the most current (HCPCS, CPT, CDT,NDC, ICD-10-CM diagnosis).

ü Monitor payer communications, state and federal mandates to install timely system modifications.

 
 
 

Situation Provider’s Responsibilities

Decrease submission of paper claims by submitting COB, attachments (PWK) or notes (NTE) on electronic claims.

ü The Health Insurance Portability and Accountability Act (HIPAA) applies to insurance payers, providers and EDI vendors. This means that Anthem and EDI vendors are required by law to accept all claim types using the "ANSI 837" (HIPAA) format. Is your EDI vendor compliant?

ü Anthem encourages providers to contact the EDI vendor to initiate the process of filing claims with other coverage, attachments and notes electronically. Providers do not have to understand the ANSI 837 format but should be knowledgeable about the appropriate information required to successfully transmit to Anthem.

ü The EDI vendor should be familiar with the 837 Implementation Guides and Anthem Companion Guide that fully explain the COB, PWK and note process. Anthem’s Companion Guide is available to providers and EDI vendors at www.anthem.com/edi. Select "Virginia" and then the Anthem Companion Guide.

 
 
 

Situation Provider’s Responsibilities

Taking action when provider has not received payment for claims submitted electronically.

ü Verify with the EDI vendor that the claims were submitted to the payer and no transmission difficulties occurred.

ü Verify with internal staff and / or EDI vendor that the claims submitted electronically were submitted with the correct provider number and payment indicator.

ü Check with the EDI staff to determine if error reports from the EDI vendor and /or Anthem are being worked and is the office up to date on error correction/re-submission.

ü Verify with the EDI vendor and determine that no transmission issues occurred between the providers practice management system, the vendor and / or Anthem.

ü Determine if the EDI vendor is current with error correction/re-submission and whether any transmission issues occurred prior to sending information to Anthem

ü Contact the EDI vendor directly and request a copy of the Anthem acknowledgement if the EDI vendor is modifying Anthem’s reports.

ü Make corrections to the information and re-submit the claim electronically if Anthem did error the claim.

ü Visit our Web site at www.anthem.com/edi "Reports and Acknowledgements" for help with resolving errors.

 
 
 

Situation Provider’s Responsibilities

My claims are rejecting for data that I never sent on my electronic claims in the past, why?

ü Verify with the EDI vendor that the claims were submitted to the payer and no transmission difficulties occurred.

ü Verify with internal staff and / or EDI vendor that the claims submitted electronically were submitted with the correct provider number and payment indicator.

ü Check with the EDI staff to determine if error reports from the EDI vendor and /or Anthem are being worked and is the office up to date on error correction/re-submission.

ü Verify with the EDI vendor and determine that no transmission issues occurred between the providers practice management system, the vendor and / or Anthem.

ü Determine if the EDI vendor is current with error correction/re-submission and whether any transmission issues occurred prior to sending information to Anthem

ü Contact the EDI vendor directly and request a copy of the Anthem acknowledgement if the EDI vendor is modifying Anthem’s reports.

ü Make corrections to the information and re-submit the claim electronically if Anthem did error the claim.

ü Visit our Web site at www.anthem.com/edi "Reports and Acknowledgements" for help with resolving errors.

 
 
 

Situation Provider’s Responsibilities

Confirming EDI vendor has delivered files / responses to or from Anthem EDI Solutions.

ü Monitor daily reports generated either by Anthem or the EDI Vendor acknowledging file receipt and / or delivery

ü Contact the EDI vendor to determine if the file pickup and delivery for your office are on schedule.

ü Ask the EDI vendor when your files were submitted to Anthem. All transactions received after 4:30 p.m. will be processed by EDI Solutions on the next business day.

ü Determine if the EDI vendor is experiencing unresolved connectivity, delivery or transmission errors with EDI Solutions.

ü View claim status and remittance information on Point of Care if the provider has access to the service.

ü Contact EDI Solutions with the EDI vendor identification number, date of submission and basic claim detail to determine if the transmission has been received.

 
 
 

Situation Provider’s Responsibilities

Confirming delivery of Anthem responses to EDI vendor.

Anthem reports:

ü Refer to Acknowledgement and Reports section of Anthem’s web site www.anthem.com/edi or companion guide for details on interpreting, formatting and resolving Anthem reports.

EDI vendor reports:

ü Refer to the EDI vendor for additional information and instructions on how to read, interpret and use reports generated from the EDI vendor’s office.

NOTE: Providers contacting Anthem with report questions should have access and reference Anthem reports. Anthem is not familiar with the proprietary report (s) generated by each of the EDI vendors and may not be able to provide assistance.

 
 
 

Situation Provider’s Responsibilities

Reconciling information on EDI vendor reports with information on Anthem Point Of Care.

"EDI vendor report (s) indicate that the claim was submitted to Anthem however the claim cannot be located on Anthem Point of Care."

ü Check with your EDI staff to determine if error reports from the EDI vendor and/or Anthem are being worked and the provider office is up-to-date on error correction/re-submission.

ü Determine if the EDI vendor is current with error correction/re-submission and whether any transmission issues occurred prior to sending information to Anthem.

ü Contact the EDI vendor directly and request a copy of the Anthem acknowledgement if the EDI vendor is modifying Anthem’s reports to verify the Anthem response.

ü If Anthem’s reports indicate claims were received, contact Anthem directly for further research. If Anthem reports indicate the claims were not accepted, providers should work with their EDI vendors to identify the claims, make the appropriate corrections and re-submit the claim(s) electronically.

Visit Acknowledgements & Reports on our Web site at www.anthem.com/edi for report specifications and help with error resolution.

 
 
 

Situation Provider’s Responsibilities

Which Anthem report confirms that claims submitted to Anthem were accepted during the timely filing period?

ü Anthem delivers daily responses to each of our electronic submitters, indicating if the claim’s approval or error response status. The response file is called "Adjudicated Claims Response File" which Anthem recognizes as proof of timely filing. If the report shows that the claim was in an "Approve," "Pend," "Reject," or "Inquiry" status, then Anthem has forwarded the claim to an adjudication system for further processing. If the report shows that the claim was in an "Accept" or "Error" status, the claim was not forwarded to an adjudication system for further processing. (Providers must identify the error, make the necessary corrections and re-submit the claim electronically to Anthem for consideration.)

ü Contact the EDI vendor directly and request a copy of the Anthem acknowledgement if the EDI vendor is modifying Anthem’s reports.

Visit Acknowledgements & Reports on our Web site at www.anthem.com/edi for report specifications and help with error resolution.

 
 
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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use