Passport Health Plan (KY) - Kentucky Medicaid, A Managed Healthcare Organization, Medical Assistance, Medicaid, Medicare, Medicare Part D, Passport Advantage, Centers for Medicare & Medicaid Services (CMS), PDP, managed care health plan, Medical Assistance recipients, Health Insurance, Healthcare, Kentucky Childrens Health Insurance Program, KCHIP, AmeriHealth Mercy, extensive provider network, Physicians, specialists, pharmacies and hospitals Improving the Health and Quality of Life of our Members
 About Us  |  Providers  |  Members  |   Miembros  |  Pharmacy  |  News  |  Contact  |  Passport Advantage
Passport Health Plan Home > Passport Health Plan > Providers > Billing Information > EDI Questons & Answers > EDI Claims
Providers
Login to Secured Services
Provider Communications
Bullet Provider Alerts
Bullet Provider Letters
Bullet Medical Office Notes
Bullet Provider Newsletters
Bullet Pharmacy News
Bullet Provider Services Year In Review
Services
Bullet Provider Recognition Program
Bullet Cultural & Linguistic Services Program
Bullet Provider Foreign Language Report
Bullet Pharmacy Services
Bullet Orientation, Workshops & Roundtables
Resources
Bullet Provider Manual
Bullet Provider Directories
Bullet Provider References
Bullet "How To" Tutorials - Authorizations & Referrals
Bullet HIPAA
Bullet Links to KCHS Department for Medicaid Services
Billing Information
Bullet EDI Questions and Answers
Medical Guidelines
Bullet Clinical Practice Guidelines
Bullet Health & Wellness: Important Member Information
Bullet QI Program Description
Bullet Summary of Annual Evaluation
Contact Information
Bullet How to Contact Passport Health Plan
Bullet Contact a Provider Representative
Website Evaluation Form
 
 

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 at ediphp@kmhp.com 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 WebMD, whether through direct submission or through another clearinghouse/vendor, you can submit claims electronically.

WebMD 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 WebMD and Other Electronic Vendors
   

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

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

Accepted claims are passed to the Plan, and WebMD returns an acceptance report to the sender immediately. Claims forwarded to the Plan by WebMD are immediately validated for provider identification number requirements. Claims that do not meet this requirement are rejected and sent back to WebMD, 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 WebMD 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 WebMD data requirements.

IMPORTANT: WebMD 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 WebMD 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.

 
 
©2008 Passport Health Plan. Home | Partnership Login | Site Map | Email-to-Friend | Print | Search
Legal Statement & Terms of Use Visit AmeriHealth Mercy
National Committee for Quality Assurance - NCQA - Excellent Accreditation