Electronic Data Interchange (EDI)
Get Paid
What happens to claims once they are received ? (see diagram)
- Claims are submitted to the EDI system by the trading partner. A trading partner could be a provider office, clearinghouse or billing service.
- Claim files are stored on the EDI system in the trading partners electronic mailbox.
- Claim files begin their journey through the EDI system by the acknowledgement of a readable file. The Transaction Acknowledgment Report (TRN) is generated at this point.
- If the file is acknowledged as a readable claims file a 997 report will generate. This report provides status of files after file level editing has occurred.
- Claim files that successfully pass the file level editing (997) will be subject to extensive claim level editing.
- The results of the claim level editing will be reported on the claims confirmation report sent to the trading partner mailbox.
- All claims that pass the claim level editing will be forwarded to the payer for adjudication.
I’ve submitted my claims - now what???
Reports generated by the EDI system are returned to the electronic mailbox of the user (trading partner) who submitted them. It is the responsibility of the provider to review and take action on the reports.
- If a provider is submitting claims directly to the EDI system, the response reports will be returned to the provider’s electronic mailbox.
- If a provider utilizes a clearinghouse, the response reports are returned back to the clearinghouse. Then the clearinghouse should deliver these reports back to the provider for review.
Transaction Acknowledgement Report (TRN) – This report generates as soon as the file enters the EDI system. This report acknowledges whether or not the file is readable. If the following notation does not appear on this report please contact the EDI HelpDesk:
***No input validation problems***subsequent reports to follow***
997 Report – This report will also generate with each file sent through the EDI system. If the claims confirmation report does not follow this report, it is likely that the file contains compliance (format) errors. The EDI HelpDesk can assist you in locating the problem.
What is the Claims Confirmation Report? (see sample)
The link above is an example of the Claims Confirmation Report, which is generated by the EDI system usually within four hours of the receipt of the claims file. The report has an .rpt extension when downloaded from the trading partner mailbox.
Why is this report important?
Claims received electronically are subject to “up-front editing.”
- All errors (file, batch, and claim) must be corrected and resubmitted.
- If a file level error occurs, the entire file is rejected, even if there are no batch or claim level errors.
- Claims showing an ERROR are rejected and must be corrected and re-filed by the trading partner. A description of the data in error will be displayed along with the name of the patient whose claim rejected. Claims rejecting as an ERROR on this report will not be forwarded to the payer for payment.
- Claims showing as WARNING will be passed to the payer. The provider should correct whatever is causing the WARNING, since edits listed as a WARNING will eventually reject as an ERROR after a certain period of time.
- Claims listed under the “Claims Without Errors List,” will be forwarded to the payer for adjudication.
Note: Claims accepted by the EDI system and passed to the payer may still be denied by the payer for various reasons.
* For more information on reports please refer to the Response Reports Manual
Who do I contact if I’m not receiving this report?
- If a provider has been assigned a trading partner number, the EDI HelpDesk may be contacted regarding any questions on reports. When making inquiries through the EDI HelpDesk, if the trading partner number is not known, assigned provider numbers must be identified in order to receive assistance.
- If a provider is utilizing a clearinghouse, inquiry should be made to the clearinghouse on delivery schedule for the response reports.
- Some vendors automate the report downloading process. In this case, a provider should contact the vendor for instruction on this process.
- If a provider is utilizing a billing service, inquiry should be made to the billing service on whether these reports are being received and reviewed
* For more information on reports please refer to the Response Reports Manual
- Back -
