EDI Enrollment Webinar

for Practice Insight Authorized Resellers

Martha Johnson, Dir. Of Payer DevelopmentDonna Anderson, Supervisor of EDI Enrollment

Jes Wettstein, EDI Enrollment SpecialistJessica Moran, EDI Enrollment Specialist

Topics we will cover…

EDI Enrollment- What IT IS, What IT IS NOT Profiling your Customer Managing the EDI Enrollment Forms

(Claims/ERAs) Tracking EDI Enrollment Requests Avoiding EDI Enrollment Problems (Delays!) Enrolling your customer for Real-Time

Eligibility

EDI Enrollment:What IT IS, What it IS NOT.

EDI Enrollment IS:

a request by the provider made to a payer to allow the exchange of specific EDI transactions with that payer. The provider is already known to the payer.

EDI Enrollment IS NOT:

credentialing or registering the provider’s NPI# or Tax ID # with the payer.

837 – Claims

835 – Remittance Advice (ERA)

270 - Eligibility Request

276 – Claim Status Inquiry

275 – Attachments (paperwork)

5 Types of ANSI Transactions

Profiling Your New Customer

Good questions to ask:

Single office or CBO? Sharing Tax ID# with hospital or other

office? How many billing NPI#s tied to the Tax ID#? For each payer, does the provider bill as a

group or are the individual providers billing “solo”?

Professional claims and/or Institutional claims?

First things first!

Login to EDIinsight

Add the NEW CUSTOMER ACCOUNT

Get the basics input to the account: Name, Address, Tax ID#

Profiling Your New Customer

Profiling Your Customer

Add the Provider Records in EDI Customer Account: Provider Name, Address Person or Non-Person? Billing or Rendering? NPI# Tax ID# Taxonomy (Specialty) Code Medicare PTAN#, Medicaid ID#

Profiling Your Customer…

Create a Payer Inventory List

Build a list of your Customer’s Top PayersMake a list of government payers

your customer needs: Medicare Part A/B, DMERC, Medicaid, BCBS, Railroad Medicare, Tricare

Make a list of commercial payers your customer needs: Aetna, CIGNA, Humana, United Healthcare, commercial Medicaid Managed Care plans (MCO)

Create a Payer Inventory List

Build a list of Payers that currently send Electronic Remits to your Customer. Note how each ERA is delivered to your Customer:

Clearinghouse, Provider/Web Portal, other direct delivery to Customer

Add to the list any additional Payers from which the Customer would like to have Electronic Remittance files.

Profiling Your Customer

Profiling Your Customer

Create a Payer Inventory List

Compare the inventory list to the Practice Insight payer list and look for gaps.

Pay attention to Professional vs. Institutional.

If payer is not found, contact us with your request, including payer ID# (log an Issue or email: enrollment@practiceinsight.net).

Time to PlayWhose Enrollment is it

Anyway?

837 (Claims), 835 (ERAs), 270 (Eligibility), 275 (Attachments), 276 (Claim Status)

1st QuestionName / Describe 2 types of ANSI transactions that we have discussed.

Answer:

Whose Enrollment is it Anyway?

What should you do BEFORE your customer submits any EDI enrollment paperwork to payers?

2nd Question

Set up customer in EDIinsight. Add customer and provider record(s).

Answer:

Whose Enrollment is it Anyway?

Single Office or CBO? Do you share tax ID # with another office? How many billing NPI #s in your office? Do your providers bill as a group or as individuals, and for which payers? Do you bill professional, institutional or both?

3rd QuestionWhat is a good question you can ask your new customer to learn about how they file claims?

Answer:

Web page where Practice Insight keeps library of

EDI enrollment documents:

http://www.practiceinsight.net/RESELLER_Docs/Enrollment.html

(This site is for Resellers, not Providers!Go ahead and bookmark this URL.)

Where are the forms?

Fill Out EDI Enrollment Forms for Each Billing Provider

Who is the Billing Provider for this Payer? What NPI# is used to bill this Payer, e.g, group

NPI# or individual provider’s NPI#? Is there more than 1 Billing Provider/NPI? Address should match credentialing at Payer Signatures must be Authorized

If any question about how the Customer is billing the Payer, CALL the Payer and Ask!

Payers typically deliver ERA files to one trading partner only at a time—no duplicate delivery

Once enrolled, Payer will send ERA files for all payments, whether the claim was submitted by Practice Insight or not

Changing existing ERA authorization may require additional LOA (letter of authorization) on provider letterhead—check PI instruction page

ERA delivery to EDI Customer account depends on complete and accurate input of provider Tax ID and NPI numbers

Fill Out EDI Enrollment FormsElectronic Remits

What if I don’t find forms?Government Payers

No forms? Contact enrollment department.

Govt. Payers require 6-10 weeks to develop a new direct connection and approval to submit claims or a new transaction type.

Electronic Remits must also be developed or contracts negotiated for Practice Insight to register and deliver these files

Questions? Create an issue.**Distinguish between Professional vs. Institutional Example: Medicare Part A and Medicare Part BPI may need to test with Medicare Part A “Institutional”

Managing the EDI Enrollment Forms Always download a current set of payer

enrollment forms (Refer to Reseller Docs URL)

Distribute Forms to Customer (Do not give out URL) Ideal time frame- 30 days before the go-

live date (forms do change) Always check PI instructions for how to

deliver forms Always make a copy of the completed

enrollment form

Tracking EDI Enrollment Requests

PI will share with Reseller any Payer confirmations or rejections (usually by email)

Some payers send NO notification to Practice Insight or to the provider Reseller can follow-up with payer Call with your copy of forms in hand—

Payers often ask for Provider NPI, Tax ID or legacy PIN

Time to PlayWhose Enrollment is it

Anyway?

What instructions should you refer to when completing and submitting EDI enrollment forms?

1st Question

Answer :The “Practice Insight” instruction page that precedes each set of EDI Enrollment Forms posted to the PI Reseller Forms’ Library.

Whose Enrollment is it Anyway?

If the Customer’s Go-Live date is February 1st, what date should you target to send completed forms to the payers?

2nd Question

Answer :January 1st. Allow approx. 30 Days. Enrollment varies from payer to payer. (ERA setups can take longer, 4-6 weeks.)

Whose Enrollment is it Anyway?

Copy of the completed forms submitted to the payer. It’s also helpful to know the date the request was submitted.

3rd Question

Answer :

When following up on an EDI enrollment request, what should you have in front of you?

Top 5 “Action Needed” (From Practice Insight):

Missing Signature Missing NPI or TAX ID Nothing Selected on

Form Missing Valid Billing

Address Illegible

Top 5 Rejections (From Payer):

Enrolling w/ wrong PTAN (Individual vs. Group)

Provider Not Credentialed Unauthorized Signature Missing PTAN, Legacy,

etc. Didn’t Select Change CH

Avoiding EDI Enrollment Problems

Avoiding EDI Enrollment Problems

Always download the latest documents

Assist your customer Proof read NPI numbers and Tax ID

numbers Make sure no missing signatures

Enrolling your Customer for Real-Time Eligibility

Payers that DO require Eligibility Enrollment: CMS Medicare including all Medicare A/B,

Railroad Medicare and DMERC. Special Payers – these are found on the

PI web site, along with forms and instructions.

Enrolling your Customer for Real-Time Eligibility

Payers that DO require Eligibility Enrollment: Complete Practice Insight 270/271

Registration Form for each customer. For any Special Eligibility Payers, go to

the RT Eligibility web page to access Payer form.

Time to PlayWhose Enrollment is it

Anyway?

Contact PI’s EDI Enrollment dept. Log an issue in Issue Manager, call the Enrollment Dept, or send email to enrollment@practiceinsight.net. Be sure to include the electronic payer id (usually 5 digits) and any information you have about the payer.

1st Question

Answer:

If your customer requests a payer and it is not on the EDI payer list, what should you do?

Whose Enrollment is it Anyway?

Missing signature. Illegible. Missing or Invalid Provider Numbers, e.g, such as Provider ID #, PTAN # NPI #, Tax ID #. Incorrect Provider name. Individual provider information on form instead of billing provider group information.

2nd QuestionGive 2 or more reasons why an EDI enrollment request might be rejected or delayed.

Answers:

Whose Enrollment is it Anyway?

Watch for an email, fax or letter from the payer.You (the PI Reseller) may receive a CONF email from Practice Insight. You or your customer can call the payer to get verbal confirmation that the provider is approved to submit claims via Practice Insight.

3rd QuestionHow will you know when your customer is enrolled and can begin submitting claims?

Answer:

In Summary…

Take the time to PROFILE YOUR CUSTOMER to get a complete and accurate assessment of the customer’s EDI enrollment requirements.

SETUP THE CUSTOMER IN EDI (add customer record and provider records) BEFORE SUBMITTING EDI Enrollment paperwork.

In Summary…

Support your provider -- they need your help!

Assist your customer in completing and reviewing EDI enrollment forms.(Rejected EDI enrollments create unnecessary and painful delays!)

EDI enrollment can be part of your implementation services and fees

In Summary…

Manage your customer’s expectations about length of time to complete enrollments and when they will be ready to “go live” with EDI.

Track the EDI enrollments so that you are aware of rejections and confirmations as soon as possible.

In Summary…

Monitor the first batch of claims your new provider sends to Practice Insight –react quickly to claim rejections.

Making your customer’s first experience positive with EDIinsight can be critical to your success. Customers always remember whether the start-up was smooth or rocky!

In Summary…

As with all EDIinsight issues, contact Practice Insight when you need help.

To reach PI’s Enrollment Dept…Log an issue in Issue ManagerSend email to

enrollment@practiceinsight.netCall 713.333.6000 (press Option #2)\

1st BONUS QUESTION!!!!

Electronic Remittance Advice (electronic eob)

Answer:

What is an ERA?

2nd BONUS QUESTION!!!!

Electronic Funds Transfer (monies deposited in bank)

Answer:

What is a EFT?

3rd BONUS QUESTION!!!!

ERA is received via electronic file. EOB is received on paper.

Answer:

What is the difference between an ERA and an EOB?