EFT Process Checklists

Transcription

1 WEDI Strategic National Implementation Process (SNIP) WEDI SNIP Transactions Workgroup EFT Sub workgroup EFT Process Checklists Implementing a Healthcare Payment EFT Process Payer and Provider Checklists July 3, 2012 Workgroup for Electronic Data Interchange 1984 Isaac Newton Square, Suite 304, Reston, VA T: //F: Workgroup for Electronic Data Interchange, All Rights Reserved

2 Disclaimer This document is Copyright 2012 by The Workgroup for Electronic Data interchange (WEDI). It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. If you require legal advice, you should consult with an attorney. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by the Workgroup for Electronic Data Interchange. The listing of an organization does not imply any sort of endorsement and the Workgroup for Electronic Data Interchange takes no responsibility for the products, tools, and Internet sites listed. The existence of a link or organizational reference in any of the following materials should not be assumed as an endorsement by the Workgroup for Electronic Data Interchange (WEDI), or any of the individual workgroups or sub-workgroups of the WEDI Strategic National Implementation Process (SNIP). Document is for Education and Awareness Use Only

3 Payer Task Coordinate with bank to receive CCD+ transaction and process through ACH determine format needed to initiate transaction (if special agreement in place and CCD+ not used). The Healthcare EFT standards IFC requires that health plans transmit the CCD+ to the bank to initiate transaction. Or, if health plan sends a different format to the bank, then it is the health plan s responsibility to make sure that the bank (or other intermediary) uses the Healthcare EFT standards; i.e, the CCD+ and TRN Segment. Develop the CCD+ transaction for transmission to the bank for EFT initiation (unless other format agreed upon with bank, then develop that format) Determine requirements for enrollment process what information is needed from the provider, what validation needs to be performed, what system setups should be completed, what requirements the ODFI may have Create Pre-Note process to validate account information provided during the enrollment process (optional) Determine what acknowledgements and reports will be returned to the provider, and for what situations. Complete system development needed for these reports. Determine if end-to-end testing will be performed with each provider. If yes, then will need to develop a process to generate small deposits for each provider, and corresponding 835 files for those deposits.

4 Provider Task Coordinate with bank to receive EFT deposits. Confirm with bank that they will deliver CCD+ Addenda information needed to reassociate transactions (provider must request this). Determine account requirements to ensure payments can be received as needed for Reassociation and posting. Coordinate with payer to understand how they pay claims TIN or NPI, based on Pay-To provider on the claim or per provider contract Complete payer enrollment process what information is needed from the provider, what validation needs to be performed, what system setups should be completed Monitor Pre-Note process from payer to provider s bank, confirm pre-note to ensure production process will be initiated (if pre-note available) Develop internal processes for monitoring and auditing of acknowledgements / reports received for EFT process and how to handle exceptions, including process for handling $0 remittances with no corresponding EFT Develop process for auditing receipt of EFT and/or ERA files, determining if exception or missing file occurs, working with payer to research missing files Develop Reassociation process to match EFT files received with corresponding remittance (either 835 or paper) either automated or manual Reassociation. If end-to-end testing will be performed with payer, monitor test process, confirm receipt of small deposit, confirm receipt of corresponding 835, and complete Reassociation process for EFT and 835 files

5 Acknowledgments WEDI EFT SWG Co-Chairs Pam Grosze, PNC Bank Deb Strickland, TIBCO Ron Meier, HealthNet The co-chairs wish to express their sincerest thanks and appreciation to the members of the EFT Subworkgroup who participated in the creation of this document.