VI. CLAIMS EDI PROCESSING PROCEDURES A. General Information

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1 A. General Information Electronic submission of claims helps to speed the processing and ensure accuracy and security. While direct submission of claims is allowed, this option is more practical for large provider groups and facilities. Many providers and billers may find that a more realistic method is to utilize a claims clearinghouse. Claims data contains private healthcare information; therefore, it must comply with HIPAA regulations. For electronic claims, data exchanged by IEHP must comply with the ANSI ASC X12 standards as well as the IEHP companion guide. For purposes of claims data interchange, these standards apply to the claims data, claim receipt, claim status acknowledgements, and claims payment remittances. The standards also dictate data requirements and the appropriate file formats. For a better understanding of these formats, visit the Washington Publishing Company at The Washington Publishing Company is responsible for the maintenance and distribution of the officially sanctioned implementation guides for each file type. Whether a provider, facility, or third party, claims can be directly submitted to IEHP for purposes of payment. There are several steps that must be completed in order to be certified: Submitter Enrollment o Enrollment Form Completion o Contract, Trading Partner Agreement, or Business Associates Agreement with IEHP o Submitter ID/Submitter SFTP account assignment EDI Testing o SFTP connection testing o X12 implementation guide file format validity testing for all relevant file types o IEHP companion guide validity testing for all relevant file types o Clean claim data validity Submitter Certification for each relevant file type o Provisional approval at successful conclusion of all testing o Formal notification of Submitter approval After all of these steps are completed, the submitter is eligible to directly submit electronic claims to IEHP. This document will describe the steps in process to become a direct electronic claims submitter and the expectations after certification is complete.

2 B. Enrollment Process 1. Enrollment Form To ensure a smooth enrollment process, a completed enrollment form should be submitted to the EDI department at IEHP, providing all information need to get started. This includes details about the enrollee, the primary and technical contacts, and the types of claims EDI transactions being requested, 837I/837P/835. If the enrollee will be submitting for multiple providers, the attached schedule can be used to list the providers. After the form is completed and signed, a scanned copy can be ed to IEHP at edi@iehp.org. The enrollment form can also be used when a change is required, such as a change of address or a submitter needs to be added to or removed from the schedule. The enrollment form can be used to cancel enrollment as well. 2. Trading Partner Agreement In addition to the enrollment form, a trading partner agreement (TPA) may be required in some circumstances. In the case that the enrollee will be acting as a third party agent for the claims submitter, such as with a clearinghouse, biller, or bank, a TPA will be needed. This agreement clarifies the HIPAA and HITECH privacy and security responsibilities of IEHP and the enrollee. If required, a hardcopy signed original should be returned by mail to: Compliance Department Inland Empire Health Plan P.O.Box1800 Rancho Cucamonga, CA If a copy of the signed TPA is sent along with the enrollment form by or fax, the enrollment process can continue without delay. 3. Submitter ID & SFTP Account When the enrollment form and a copy of the TPA have been received, the EDI department will generate a submitter ID and begin configuring the enrollee's submission details in our systems. Credentials on IEHP's SFTP server will be created based on the submitter ID also. The submitter ID is an important identifier. It should be included in all submitted claims files and will be used for tracking EDI transactions, EDI reporting, and troubleshooting. The SFTP will be used in the exchange of all claims data. The credentials assigned to enrollees will provide access to post claims files and retrieve response files. Security is at the highest priority when dealing with healthcare information. Credentials should be kept private.

3 C. Testing & Certification Testing occurs at several levels for new enrollees. IEHP's Companion Guide (CG) should be reviewed in conjunction with the X12 Implementation Guide (IG) for the 837I and 837P transaction types. The CG can be found in the IEHP EDI Manual Online at 1. SFTP Connection Testing After the submitter ID and SFTP credentials have been created, a new enrollee will work with an EDI Specialist to test the connection to the SFTP server. Test files will be uploaded and downloaded to ensure no problems exist with the credentials before moving on to testing claims files. 2. Implementation Guide/Companion Guide Testing During the IG/CG testing, submitters will be asked to post 837I and/or 837P test files of between 25 and 150 records to specific test subfolders on the SFTP to be evaluated for compliance with the X12 Implementation guide and the IEHP Companion Guide. Providers are also urged to utilize third-party testing services, like those offered by EDIFECS ( prior to submitting to IEHP to insure X12 standards are met. The EDI Specialist uses several tools to analyze test files and validate against the IG and CG file format requirements, verifying that all loops and segments are included as required. Any issues found will be documented and reported back to the submitter for investigation, correction and submission of a new test file. This step may repeat several times, until all concerns have been address. After the EDI Specialist has indicated that test files are consistently showing no signs of structural errors over several iterations, the files will be advanced into the next phase of testing. 3. Clean Claim Data Validity During this phase of testing, test files are sent through end-to-end system processing to ensure all data that is required, for the successful payment of a claim. is present and valid. Items under review consist of: valid diagnosis and procedure coding, correct dates of service, presence of the service location, billing and rendering provider information, member identifiers, and member eligibility. Please review the list of edit checks to understand the types of issues that will be rejected by the test system. The EDI Specialist will document and report any issues to the submitter and request additional test files as needed until tested files consistently pass at or below the acceptable rejection rate.

4 C. Testing & Certification 4. Rejection Rate and Auditing The primary motivation to submit electronic claims is to ensure the secure, accurate, and timely processing of electronic claims. Rejected claims can jeopardize the integrity of our electronic claims processes by requiring manual intervention and resource expenditure. A standard rejection rate is used as an indicator of electronic claims utility. IEHP considers a rejection rate at or below 5.0% to be within acceptable limits. During testing this rate must be met consistently before testing can be concluded. Once in production, an aggregate rejection rate at or below 5.0% must be maintained to remain eligible to submit claims electronically. If, during audit analysis of submissions, the rate is determined to be higher than 5.0%, IEHP may request a return to the testing phase to identify issues and resolve them before continuing to submit electronic claims. 5. Electronic Submission Certification At the successful conclusion of all phases of testing, a provisional certification will be issued by the EDI Specialist for each claim type tested. Initial submissions will be monitored carefully to ensure continuity with previous test results. An official certification will be issued by IEHP leadership as soon as possible after testing. Remember that certifications provided by IEHP only apply to submission of claims to IEHP and cannot be used for any other payer. Folder paths for production file posting, on the SFTP, will be different then the folder paths used for testing. Production processing schedules operate on business week schedules, with claims files on the SFTP processed at regular intervals through the course of the day.

5 D. Claims Processing 1. File Transmission IEHP utilizes a secure SFTP server for all claims file exchanges, which can be accessed directly from a browser, or through an SFTP capable client. Each direct submitter is assigned an account and a home directory on the SFTP. Within this home directory are several subfolders, each of which serves a specific purpose: sftp.iehp.org [Home Directory] 5010 inbound outbound editest inbound outbound - production claims file submitted to IEHP - production response files from IEHP - test claims file submitted to IEHP - test response files from IEHP For example, submitter '98' would have a home directory on the SFTP of '098'. 837 claim files would be placed in the '/098/5010/inbound/' subfolder. Response files would then be returned in the '/098/5010/outbound/' subfolder. The SFTP server will be available 24 hours a day, 7 days a week for posting and picking up files. Please note that claim processing only takes place during regular business hours. If for any reason IEHP s SFTP server is not accessible, please the EDI department at edi@iehp.org or call the IEHP helpdesk at (909) Provide your SFTP account user name and indicate any specific errors received. IT staff will work as quickly as possible to determine the cause and resolve the issue.

6 D. Claims Processing 2. File Naming Convention All electronic claims files must utilize our standard naming convention consisting of: Assigned Submitter ID I or P (institutional or professional type) 2 digit month, 2 digit day, 2 digit year A-Z (Daily unique file increment).837 file extension Three digits must be used for the submitter ID. The I vs. P type indicator must reflect whether the file was created in the standard X12 837I or 837P file formats. The A-Z increment will ensure file name uniqueness when multiple files are sent per day of either file type. The.837 extension indicates that the file is a submitted claims file and not a file of another type. Examples: A facility whose submitter ID is 98 submits 3 claims files on January 15 th, The file names would be: ID File Type Month Day Year Increment Extension Full Name 098 I A I011514A I B I011514B I C I011514C.837 An IPA whose submitter ID is Z submits 2 claims files on January 15 th, The file names would be: ID File Type Month Day Year Increment Extension Full Name 00Z P A.837 ZP011514A Z P B.837 ZP011514B.837 A clearinghouse whose submitter ID is XYZ submits 2 institutional and 3 professional claims files on January 15 th, The file names would be: ID File Type Month Day Year Increment Extension Full Name XYZ I A*.837 XYZI011514A.837 XYZ I B.837 XYZI011514B.837 XYZ P A*.837 XYZP011514A.837 XYZ P B.837 XYZP011514B.837 XYZ P C.837 XYZP011514C.837 *Note in this example, the increment begins at 'A' for the institutional files, and again it begins at 'A' for the professional files. It would also have been acceptable to increment the five files 'A' through 'E'.

7 D. Claims Processing 3. Response Files Both 997/999 claim receipt acknowledgement and 277 claims status response files are generated for each 837 claim file received. These files will share the same name as the received 837 file, although the extension will be changed to either '.997' or '.277'. The 997/999 acknowledgement file will be generated within one business day and may contain indicators of errors if an 837 file or a claim within the 837 file had significant formatting issues. This file is a good indicator as to whether a claim has reached IEHP. The 277 claim status file may take several days to post, depending on the content and complexity of the claims the original 837 file contained. The 277 will indicate whether each claim in an 837 was rejected, accepted, or accepted with errors. Once this file is generated, the EDI evaluation of the 837 file is complete. Rejected claims reported in the 277 should be reviewed, corrected, and resubmitted. Claims accepted with errors will be reviewed by IEHP claims processors for completeness. The claim will either be processed or, if found to be incomplete, sent back in a letter explaining why it could not be processed. Accepted claims will be pushed through the claims processing system for payment evaluation. IEHP places 997/999 and 277 files on the SFTP server in the '/claims/outbound/' folder in the submitter's home directory, (e.g. '/13/claims/outbound/'). Additionally, 835 remittance advice files can also be produced, but enrollment for 835s must be requested. These files differ from the 997/999 and 277 files in several significant ways. An 835 file describes the final detail payment status of all claims within a single payment/check. Additionally, they may contain claims adjusted or claims with a zero payment such as denied claims. 835 files are typically utilized by large submitters for automatic payment adjudication of large numbers of claims. Providers can also check the status of their claims by visiting the Provider section on the IEHP website at files are named with the submitter ID and the EFT/check number (e.g. '098' & 6-digit payment ID, R00) rather than an originally submitted claim file name as a payment may contain claims from multiple submissions. These files are also placed on the SFTP server in the /claims/outbound folder in the submitter's home directory.