Appendix. CTMHP EDI General Information

Transcription

1 Appendix CTMHP EDI General Information C C.1 Medicaid Billing Features C-2 C.2 Accessing the EDI Gateway C-2 C.3 Getting Started C-2 C.3.1 First Step C-2 C.3.2 Second Step C-2 C.4 Forms for Getting Started with TMHP EDI C-2 C.4.1 Electronic Funds Transfer Form C-2 C.4.2 Electronic Remittance and Status (R&S) Report Form C-2 C.4.3 TMHP EDI Submitter ID Form C-2 C.4.4 TDHconnect Order Form C-2 C.5 Vendor Implementation C-3 C.5.1 Step C-3 C.5.2 Step C-3 C Testing C-3 C.5.3 Step C-3 C.5.4 Step C-3 C.5.5 Step C-3 C.5.6 Step C-3 C.6 TMHP Website C-3 C.6.1 Accessing the TMHP Website C-4 C.7 Electronic Eligibility Verification C-4 C.7.1 Advantages to Electronic Eligibility Verification C-4 C.7.2 Access to Electronic Eligibility Verification C-4 C.8 Electronic Claims C-4 C.8.1 Advantages of Electronic Claim C-5 C.8.2 Access to Electronic Claim C-5 C.9 Online Claim Status Inquiry C-5 C.9.1 Advantages to Online Claim Status Inquiry C-5 C.9.2 Access to Online Claim Status Inquiry C-5 C.10 Online Appeal C-5 C.10.1 Advantages to Online Appeal C-5 C.10.2 Access to Online Appeal C-6 C.11 Electronic Remittance and Status (ER&S) Report C-6 C.11.1 Advantages of Electronic Remittance and Status (ER&S) Reports C-6 C.11.2 Access to ER&S Reports C-6 C.11.3 Enrollment Procedures C-6 C.12 Electronic Funds Transfer C-6 C.12.1 Advantages of EFT C-6 C.12.2 Enrollment Procedures C-6 C.13 Glossary C-7

2 Appendix C C.1 Medicaid Billing Features TMHP s Electronic Data Interchange (EDI) system was developed and implemented to improve Medicaid billing. TMHP s EDI Gateway is available to all Texas Medicaid, Family Planning, Long Term Care, PCCM-Texas Health Network, and Children with Special Health Care Needs (CSHCN) providers. Contact the TMHP EDI Help Desk at for more information. This system pays claims faster, more accurately, and with less effort from providers office staff. TMHP EDI offers the following services: Electronic funds transfer (EFT) Electronic eligibility verification Electronic claims submission Electronic claims status inquiry Electronic Remittance and Status (ER&S) report Electronic appeals submission TMHP EDI uses the following technology: HIPAA-compliant ANSI ASC X A formats for batch and interactive transactions TDHconnect, a Windows -based solution that can be used on your personal computer Electronic data interchange (EDI) through FTP and HTTP connections using standard synchronous and asynchronous telecommunications C.2 Accessing the EDI Gateway Business organizations (i.e., billing organizations, vendors, and clearinghouses) communicate with the TMHP EDI Gateway using their computer systems. EDI standards, approved by the healthcare industry, are mapped to Texas Medicaid requirements to facilitate open access. Industry standards for telecommunications are also used. All TMHP EDI electronic services may also be accessed by using TDHconnect. TDHconnect is a Windows -based software application available through TMHP. This software enables personal computers using Windows operating systems (versions 98, NT, ME, and 2000) to access TMHP EDI via dial-up modems. C.3 Getting Started EFT does not require software and you can enroll today. Instructions for EFT enrollment forms are in Forms for Getting Started with TMHP EDI on page C-2. C.3.1 First Step If you are a paper biller, determine whether you will be using a vendor or TDHconnect to submit electronic transactions. Vendors generally give different levels of support depending on your needs and often supply a medical management system to further enhance office operations. They also address both commercial and government claims. A list of certified vendors who offer TMHP EDI services can be found on the TMHP website, under EDI. Select the link labeled Production Submitter List. TDHconnect, a Windows-based software, is also available for claims processing. Instructions for requesting the TDHconnect form are in Forms for Getting Started with TMHP EDI on page C-2. C.3.2 Second Step If you use a vendor, they will guide you through implementation. If they have distributed software to you, you will need a TMHP EDI submitter ID. Instructions for requesting a TMHP EDI submitted ID are in Forms for Getting Started with TMHP EDI on page C-2. If requesting TDHconnect, installation instructions will be sent with the TDHconnect software to guide you through installation. An online manual also is built into TDHconnect and instructs you on its use. C.4 Forms for Getting Started with TMHP EDI C.4.1 Electronic Funds Transfer Form Complete the Request for Electronic Funds Transfer on page D-70 and fax to For questions about EFT enrollment, contact Provider Enrollment at C.4.2 Electronic Remittance and Status (R&S) Report Form Complete the Texas Medicaid & Healthcare Partnership Electronic Remittance and Status (ER&S) Agreement Instructions on page D-81 and fax to or For questions about ER&S enrollment, call the TMHP EDI Help Desk at C.4.3 TMHP EDI Submitter ID Form Complete the Compass21 ID Request on page D-10 and fax to or For questions about the TMHP EDI submitter System ID Order Form, call the TMHP EDI Help Desk at C.4.4 TDHconnect Order Form Complete the TDHconnect Order Form on page D-80 and fax to or For questions about the TDHconnect Order Form, contact the TMHP EDI Help Desk at C 2

3 TMHP EDI General Information C.5 Vendor Implementation The vendor may refer to the following guidelines when implementing with TMHP EDI. C.5.1 Step 1 Establish which services you will offer. C.5.2 Step 2 Contact the TMHP EDI Help Desk at for the specifications. This documentation contains all the information you need to begin testing for production except your IDs. C Testing Testing efforts must be coordinated with TMHP. Initiate the effort by filling out the intake form located in the HIPAA library. Upon receipt of a completed intake form, TMHP assigns you a testing ID, password, and a vendor test assistant. Direct questions about the specifications or testing procedures to edi.helpdesk@tmhp.com or C.5.3 Step 3 Documentation specification questions can be sent to the TMHP EDI address on the TMHP website under Contact Us, edi.helpdesk@tmhp.com, or contact the TMHP EDI Help Desk. Your should contain the following: Organization name Contact name and telephone number Fax number Best time of day to contact you Type of service (for example, eligibility, appeals) Type of format Questions The Help Desk responds to s on the same day they are received. Type of services you will be supporting (for example, eligibility, appeals) Listing of billing TPIs that will use this service Indicate if you distribute software for these TPIs or if your organization processes the transactions. C.5.5 Step 5 Vendors are encouraged to contact TMHP for testing assistance. The following steps should be followed for assisted testing: 1) Limit test files size to ten transactions or less. 2) Within 24 hours after sending the file to the TMHP EDI Gateway, send the information below to the appropriate TMHP EDI address: Access the TMHP EDI Gateway by calling ) Include the following in the text of the message: Company name Contact name Contact telephone number Submitter ID 4) Include any questions about the test submission The address for testing is found on the TMHP website at under Contact Us. C.5.6 Step 6 After you begin testing, your name and the service you are testing are added to the list supplied to providers requesting vendor status. When you have completed testing, your status is changed to Production. The testing process outlined above adds you to the Vendor Status Report distributed to providers. Reminder: Telephone communication from you takes place through the TMHP EDI Help Desk or TMHP EDI . This will enable test reviewers to fully use their time in expediting your test. TMHP EDI Help Desk C C.5.4 Step 4 Request a TMHP EDI submitter ID and password by faxing the following information to or : TMHP EDI submitter ID request Organization name Address City/State/ZIP Contact name and telephone number Fax number Tax ID C.6 TMHP Website The TMHP website furnishes library capabilities. The following examples show items in the library: Library Banner Messages Fee Schedules EDI Description Medicaid and CSHCN banner pages Medicaid reimbursement fees Overview of TMHP EDI C 3

4 Appendix C C.6.1 Accessing the TMHP Website For initial access to the TMHP website, follow the procedures listed below. When you begin implementing TMHP website services, you are assigned your own user identification. Using your ISP, go to provider.tmhp.com. Click Activate My Account. C.7 Electronic Eligibility Verification Electronic eligibility verification is a method of accessing Texas Medicaid eligibility information using a personal computer. Eligibility information can be accessed by a business organization bridging directly in to the TMHP EDI Gateway, accessing the TMHP website, or by using the TDHconnect application, the free Windows -based software available from TMHP. Eligibility verification inquires can be submitted by using one of the following combinations of search criteria: Client s CSHCN number Social Security number and last name Social Security number and date of birth First name, last name, and date of birth The response contains detailed information about the following client eligibility aspects when applicable. Medicaid Medicare Limited Authorization or prior authorization Other insurance Medicaid managed care Benefit limitations, furnishing last services dates on dental and screening services C.7.1 Advantages to Electronic Eligibility Verification The following are advantages of electronic eligibility verification: Inquiries can be submitted using your personal computer. Inquiries for eligibility information are possible 24 hours a day, 7 days a week. The TMHP EDI system receives file updates from HHSC each business day ensuring access to up-to-date information. Span dates can be entered for a 125-day (4 month) period for each request and for three years before the current date and one future month. Interactive requests (single transactions) receive a response within 30 seconds. Batch requests (multiple transactions) receive a response within 24 hours. A report for users to print or download is generated for batch responses. Users are able to download or print interactive responses. C.7.2 Access to Electronic Eligibility Verification Eligibility verification is available to business organizations (e.g., billing organizations, vendors and clearinghouses) interfacing directly with TMHP EDI Gateway, accessing the TMHP website, or through TDHconnect. Refer to: The TDHconnect Online User Manual/Eligibility section of the TDHconnect software packet for implementation information. For all other information, call the TMHP EDI Help Desk at EDI standards approved by the healthcare industry are used and mapped to Texas Medicaid requirements to facilitate open access. Upon completion, Texas-specific formats are available for download from the TMHP EDI. Industry standards for telecommunications are also used. Electronic batch submission responses are deposited to the submitter s TMHP EDI FTP directory mailbox. The following formats are used for electronic eligibility: Interactive Inquiry and Response Batch Inquiry Batch Response ANSI ASC X A1 270 and 271 ANSI ASC X A 1270 ANSI ASC X A1 271 C.8 Electronic Claims TMHP EDI electronic claims submission is designed to pay Texas Medicaid claims quicker and with less effort from provider office staff. It is a system structured to accept both interactive (single claim) and batch (multiple claims) claim submission. TMHP EDI can be accessed by a provider or business organization bridging directly into TMHP EDI or by using TDHconnect, the free Windows based software available from TMHP. Claims are submitted to a front-end processor that contains approximately 200 edits. A warning message is returned if front-end edits detect an error for interactive claims. The submitter of a batch receives an electronic file deposited to their TMHP EDI FTP Directory mailbox reporting accepted and rejected claims within a batch. Ten header and 10 detail level errors can be returned per claim. Interactive submission has a front-end response within 30 seconds. Batched claims receive a front-end response within 24 hours. C 4

5 TMHP EDI General Information C.8.1 Advantages of Electronic Claim The following are advantages of electronic claim submission Approximately 200 front-end edits enable error identification, correction, and resubmission of problem claims in a timely manner, thereby potentially increasing cash flow by increasing the number of first-pass clean claims forwarded to the final processing cycle. Claims can be submitted 23 hours a day, 7 days a week. One hour a day (3 a.m. to 4 a.m., Central Time) reserved for system maintenance. Monthly system maintenance times are communicated through the website. Claims can be submitted interactively or in batches. Claims receive an ICN during front-end processing, helping to meet filing deadlines. The number of attachments required is reduced, enabling more claims to be processed electronically. A comprehensive processing approach has been incorporated into the system, allowing a single point of entry into the system for all Title XIX, CSHCN, Family Planning, and Long Term Care claims. BCBS and Medicare B for Trailblazer claims also can be submitted through TMHP EDI. Example: Two examples of front-end edits are verifying patient eligibility and confirming that other insurance does not exist. C.8.2 Access to Electronic Claim TMHP EDI electronic Medicaid claim submission is available to business organizations (e.g., billing organizations, vendors and clearinghouses) interfacing directly with the TMHP EDI. Contact your business organizations to determine their availability. For more information, contact the TMHP EDI Help Desk at EDI standards, approved by the healthcare industry, are used and mapped to Texas Medicaid and CSHCN requirements to facilitate open access. Industry standards for telecommunications are also used. Electronic batch submission responses are deposited to the submitter s TMHP EDI FTP directory mailbox. It is the submitter s responsibility to download the response file after each claim submission and to reformat the file in a report readable format. A TMHP Batch Number is required on every page of the response report. TMHP uses HIPAAcompliant ANSI ASC X A data formats for claim submission. C.9 Online Claim Status Inquiry Online claim status inquiry is a method of accessing Texas Medicaid, Family Planning, and CSHCN claim history using a personal computer. You can access claim status inquiry by using the TDHconnect application, a free Windows -based software available from TMHP or via the TMHP website at You have access to paid, suspended, and denied claim information, for a 24-month period, on Texas Medicaid, Family Planning, and CSHCN claims submitted under billing TPIs assigned to your organization. You can make inquiries at the provider, client, or claim level. C.9.1 Advantages to Online Claim Status Inquiry The following are advantages of using claim status inquiry: You can use the time you would have spent making inquiries over the telephone to more effectively serve your clients. You can access Medicaid, Family Planning, CSHCN, and PCCM-Texas Health Network claims any time. You can cross-reference Explanation Of Benefit (EOB) and Explanation Of Pending status (EOPS) files for more timely research. You can download or print information. C.9.2 Access to Online Claim Status Inquiry Access to online claim status inquiry is available to business organizations (e.g., billing organizations, vendors, and clearinghouses) interfacing directly with the TMHP EDI Gateway, the TMHP website, or through TDHconnect. Refer to: The Online User Manual/Claims Status Inquiry section of the TDHconnect software packet. For all other information, contact the TMHP EDI Help Desk at C.10 Online Appeal Online appeal submission is a method of submitting Texas Medicaid appeals using a PC. An appeal is a request for reconsideration of a previously dispositioned claim. The online appeals feature can be accessed by a business organization bridging directly into the TMHP EDI Gateway or by using TDHconnect. C.10.1 Advantages to Online Appeal Using online appeal submission provides the following advantages to the users: Increased accuracy of appeals filed to potentially improve cash flow. C C 5

6 Appendix C Print and download capabilities help maintain audit trails. Appeal submission windows can be automatically populated by electronic remittance and status report information, thereby reducing data entry time. C.10.2 Access to Online Appeal TMHP EDI online appeal submission is available to business organizations (e.g., billing organizations, vendors, and clearinghouses) interfacing directly with the TMHP EDI Gateway or through TDHconnect. For more information, contact the TMHP EDI Help Desk by calling or ing edi.helpdesk@tmhp.com. C.11 Electronic Remittance and Status (ER&S) Report The TMHP Electronic Remittance and Status (ER&S) report is deposited to the receiver s TMHP EDI FTP directory mailbox each Monday, by 6 a.m. The report can be accessed by a business organization bridging directly into the TMHP EDI Gateway or by using TDHconnect, the free Windows -based software available from TMHP. EOPS reference files are available through the TMHP website. C.11.1 Advantages of Electronic Remittance and Status (ER&S) Reports The following productivity improvements are gained by using TMHP ER&S reports: Increase accuracy of input Decrease employee time spent on input Increase paper storage capacity Improve research capabilities Facilitate timely reconciliation Easily create reports C.11.2 Access to ER&S Reports TMHP R&S reports are available to business organizations (e.g., billing organizations, vendors, and clearinghouses) interfacing directly with the TMHP EDI Gateway and through TDHconnect. Refer to: The Online User Manual/Electronic R&S Reports section of the TDHconnect software packet. For all other information, contact the TMHP EDI Help Desk at or fax a request to or HIPAA-compliant EDI standards are used for ER&S files. Upon completion, Texas-specific formats are available for download from the TMHP website. Industry standards for telecommunications are also used. The ER&S report will be deposited to the receiver s TMHP EDI FTP directory mailbox. Testing using an ER&S requires the provider to enroll for the ER&S feature. The following are formats used for TMHP ER&S reports: Electronic Remittance & Status (ER&S) C.11.3 Enrollment Procedures The ER&S Agreement can be found in Forms on page D-82. To enroll for the ER&S feature, providers must submit a completed enrollment form to TMHP. TMHP processes a completed form within five workdays after receipt. For questions regarding ER&S enrollment, call the TMHP EDI Help Desk at C.12 Electronic Funds Transfer EFT is a method for directly depositing funds into a designated bank account. Providers must enroll in EFT to participate. When you enroll, TMHP deposits funds from the payment of your approved claims directly into your designated bank account. Transactions transmitted through EFT contain descriptive information to help reconcile your bank account. C.12.1 Advantages of EFT ANSI ASC X A1 Claim status notification ANSI ASC X Pending Remittance & 3050 Status The following are advantages to using EFT: Stop payments are no longer necessary because no paper is involved in the transaction process. Payment theft is less likely to occur because the process is handled electronically rather than by paper. Deposited funds are available for withdrawal the Friday morning following the completed financial cycle. Upon deposit, your bank considers the transaction immediately collected. No float is attached to EFT deposits for Texas Medicaid funds. TMHP includes TPIs and remittance and status numbers with each transaction submitted. If your bank s processing software captures and displays the information, both numbers appear on your banking statement. C.12.2 Enrollment Procedures To enroll in EFT, providers must submit a completed enrollment form to TMHP. A voided check or copy of a deposit slip must be attached to the enrollment form. C 6

7 TMHP EDI General Information One form should be filled out for each billing TPI, including an original signature of the provider. Within 10 business days after receipt, TMHP processes the form. TMHP then issues a prenotification transaction during the next cycle directly to your bank account. This transaction serves as a checkpoint to verify EFT is working correctly. If your bank returns the prenotification without errors, you will begin receiving EFT transactions with the third cycle following the enrollment form processing. Until you begin receiving EFT transactions, you will continue to receive paper checks. If you change bank accounts, a new enrollment form must be submitted to Provider Enrollment. The prenotification process is repeated and, once completed, the EFT transaction is deposited to your new bank account. For questions regarding EFT enrollment, contact Provider Enrollment at Refer to: The Request for Electronic Funds Transfer on page D-70. C.13 Glossary Term Accepted Claims ANSI Banner Page Batch Batch Check Boxes Clearinghouse Claim History Claim Status Inquiry Client CSI Denied Claim EDI Edits or Audits Electronic Remittance and Status EOB EOPS ER&S Explanation of Benefits (EOB) Description Electronically processed claims that have passed acceptance edits, been assigned an ICN, and will be paid or denied in the TMHP system. American National Standards Institute A message from TMHP that contains new or updated information regarding the Medicaid program. You can download these pages from the TMHP website or at One or more transactions grouped together for the purpose of electronic delivery to TMHP EDI for processing. One or more transactions grouped together and submitted for processing. Submitters receive a response to the batch submission normally within 24 hours. Selection boxes that represent the file to which it is next. The box is filled with a check mark or X if it is selected. It is blank if it is not selected. An organization where providers can submit electronic claims and have them disseminated to various payors, such as Medicaid, Medicare, and private insurance companies. A record of all accepted claims submitted into the Medicaid program. An electronic transaction requesting information on the status of a claim previously submitted for processing. An individual determined by the Texas Department of State Health Services or the Texas Department of Aging and Disability Services as eligible for Medicaid services. Claim Status Inquiry A claim that has been denied for payment because it has not passed all program edits. Electronic Data Interchange Claims processing check points that verify field validity and compliance with business rules. Edits apply to the claim in process and other claims in the client s claim history. Electronic version of the providers weekly status report that gives detailed information on claims submitted. Explanation of benefits Explanation of pending status Electronic Remittance and Status report An explanation of the payment or denial of a provider s claim, which appears on the provider s R&S report. C C 7

8 Appendix C Term Explanation of Pending Status File Acknowledgment Finalized Claim Front-End Edits Icon Interactive Internal Control Number (ICN) Local Edits Local Reference Database Pending Claim R&S Rejected Claim Suspended Claim TDHconnect TMHP EDI Gateway TMHP EDI Library TMHP EDI Library ID TPI Texas Provider Identifier Transaction Transmission Transmission ID Description An explanation of the claims that are in process and not finalized on the R&S Report. The acknowledgement indicates the success or failure of a file transmission to TMHP EDI. A claim that has completed processing through TMHP EDI and has a paid or denied status on the ER&S. Business rule edits that determine if an electronic claim will be accepted into the system or rejected back to the provider for correction. These are validity edits and do not imply that he claim will be paid or denied because of program edits. A graphic button in a Windows environment. When selected, it results in some action. For instance, clicking the Flashlight icon accesses the local reference database. of a single electronic transaction that receives a response during one telephone call (modem connection). A number assigned to uniquely identify an accepted claim. Pretransmission checks that verify required information is present on transmitted claims. Local edits run either when a claim is submitted as an interactive transmission or when a claim is saved for batch submission. A database within TDHconnect that stores and manages client and provider data, as well as reference codes. See Suspended Claim Remittance and Status reports An electronically submitted claim that has not passed the acceptance edits and is returned electronically. You must correct the errors and resubmit the claim before the claim will be processed. Rejected claims do not appear on the R&S and do not receive an ICN. One or more batches grouped together and submitted to the TMHP EDI Gateway for processing. The retrieval of response(s) to the submission takes place at a later time. A claim that has failed a program edit and is pending edit resolution before continued processing. A Windows -based application on your personal computer. It supports claims submission, Medicaid eligibility, claim status inquiries, appeals, and downloading of reports. The TMHP EDI Gateway receives claim and eligibility batch submissions that you send. It stores the transmission responses for download. The informational library where you can download user guides and updates, banner pages, updated reference file information (such as explanation of benefits [EOB] codes), and reference files. The ID and password used to access the TMHP Library. A unique nine-character number assigned to every provider. The number is composed of a seven-character base that identifies each provider and a twocharacter suffix. A suffix will be assigned to the seven-character base identifier for each type, specialty, subspecialty, location, tax identification number, and Medicare number assigned to a provider. A single electronic request for processing, such as a claim or an inquiry request. An electronic file that consists of one or more batches of transactions. An alphanumeric ID assigned to all electronic batch transmissions. It is returned electronically to the provider after the transmission is received and verifies that the transmission was received. C 8