Submitting Claims Electronically

Note: A small number of our payers accept claims through clearinghouse companies that charge fees to claim payers. If you are going to be connecting through a clearinghouse, you probably won't find any useful information here; simply file the claim as directed by the clearinghouse. If you are interested in filing claims directly to payers either to avoid clearhouse fees or to file electronically with payers that don't use clearinghouses, read on.

Creating HIPAA compliant claims

Our payers are forbidden by law to accept a claim in any format other than the formats described at www.wpc-edi.com. Ask your software vendor if your medical practice software is capable of generating HIPAA compliant claims. You may also use HIPAA Scan (our free HIPAA validation tool) to test your claims for HIPAA compliance.

Implementation Guidelines

When you ask to add a payer as a "trading partner" to your EDI profile, you will receive an implementation guideline that will list the identifiers you should use in your EDI transaction. You will also receive a trading partner agreement if it is required; some payers require providers to execute a trading partner agreement prior to submitting claims electronically. The purpose of such an agreement is to clarify the meaning of codes and other values found in the HIPAA mandated transactions in ways specific to the payer.

Security

HIPAA legislation requires encryption to keep personal health information private. Our software supports both OpenPGP and S/MIME encryption standards. The software necessary to use these open standards is available free of charge from other organizations (See www.gnupg.org and www.openssl.org). It is also available from reputable commercial software vendors (See www.pgp.com and www.rsasecurity.com). Please take advantage of the normal support channel for whichever encryption program you select; we do not offer support for these software packages. If you don't have a specific reason to choose S/MIME we suggest that you select OpenPGP based on its widespread use in the EDI and Healthcare communities.

Each payer organization has their own public keys that are available from this website as part of their implementation guide.

It is important to note that:

1. YOU SHOULD NEVER SUBMIT DATA WITHOUT ENCRYPTING IT.

2. YOU SHOULD NEVER SUBMIT DATA WITHOUT ENCRYPTING IT.

3. YOU SHOULD NEVER SUBMIT DATA WITHOUT ENCRYPTING IT.

Not encrypting data prior to submission is a violation of HIPAA privacy regulations.

Transmission

After adding your own public key to your EDI profile, you will be able to submit encrypted transactions and pick up encrypted transactions left for you by payers. Remember, you must encrypt the claims using OpenPGP or S/MIME prior to submitting them; the web connection for this service is not secure for this purpose.

You may also contact Datagrove to request alternative transmission protocols such as scheduling FTP pick ups and drop offs at your FTP server.

Testing

During testing you will submit claims both electronically and on paper. Please do not discontinue submitting claims on paper until we let you know that the testing has been completed satisfactorily.

Using other Transactions

Our payers support all the required HIPAA Transactions including eligibility, claim status, and remittance advice. We suggest that you familiarize yourself with the electronic claim process before using the other HIPAA transactions, but these transactions work in exactly the same manner as described above for claim submission.

Conclusion

It is widely recognized that point to point EDI relationships can be a challenge to implement, but the initial time investment is expected to be mutually beneficial long into the future. Please keep in mind that all our payers are continuing to accept claims on paper indefinitely; you can take deliberate steps at your own pace toward the electronic future of healthcare.

©2003 Datagrove, Inc.