Medicare Part B 101 Manual

Medicare Part B 101 Manual

Electronic Data Interchange

Table of Contents

Electronic Data Interchange Transactions

National Government Services, in conjunction with the CMS, strongly encourages EDI transactions. EDI is not just about submitting claims electronically. EDI is about electronic reports, electronic remittances, EFT, beneficiary eligibility, electronic attachments, real time claim status and much more.

We all know the process of dropping a letter in the mailbox and hoping it makes it to the intended destination intact. But did you know paper claims take longer to enter into the system? It’s true. First the submitter must complete the paper CMS-1500 claim form (02/12) which must be purchased. The claims are then mailed and delivered to Medicare. We open the envelopes, separate the forms, microfilm the claims, and put the forms back together. The batch of claims is given to a claims examiner and manually keyed into the system or scanned through an optical character recognition system. It is an involved process—starting with you—the submitter. Electronic submitters can receive reports to verify claims were accepted into the processing system within 24 hours after submission. Paper claims would not even have reached us by then! But we’re here to help because EDI can change all that for you! Becoming an electronic submitter will save you so much time and money; you won’t know how you survived without it.

Here are some of the many advantages you'll receive as an electronic submitter:

  1. Eliminates paperwork and reduces errors, therefore, claims process more accurately.
  2. Improves cash flow (14-day payment floor for HIPAA-compliant claims), which saves time and money. Paper claims are not paid until 29 days after they reach us.
  3. Flexibility. Unlimited number of claims accepted 24 hours a day, 7 days a week for electronic submitters.
  4. Free telephone support from the EDI help desk.
  5. Security (unique password and submitter ID number).
  6. Receive reports verifying receipt of claim submission and acceptance into the Medicare processing system within 24 hours.
  7. Free Medicare software: PC-ACE (claims and remittances), MREP (remittances only)
  8. Value added incentives: EFT, ERA, and availability of NGSConnex which allows for online claim status inquiries, patient eligibility and view and print remittance advices.

    Please note that some of these items may require you to purchase additional software from your vendor.

Not sure you want all EDI functions at once? Try electronic claim submission to start, and we guarantee you'll want more electronic services soon after.

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Benefits of Submitting Electronically

Faster Payment

The payment floor for paper claims is 29 days. That means we wait 29 days after we receive the claim to release payment. That usually translates into well over a month. The payment floor for electronic claims is only 14 days. This is especially helpful when you resubmit a claim; the turnaround time is half. Even if you don’t accept assignment, since the patient gets paid faster, they won’t be calling your office to inquire about the status of their payment.

Less Chance for Errors

Since the information you key into your computer is exactly what gets entered into our computer, this eliminates most typographical errors. Even if you use a computer to generate paper claims, the chance of typographical errors is greater.

More Efficient

If you're submitting paper claims, you're wasting an enormous amount of time. Once the patient data is entered into a computer, you never have to fill out the information on a claim again. This saves time, and also reduces the chance that you may make a mistake. Remember, you're mandated by federal law to submit Medicare claims. Shouldn’t you do it in the easiest way possible?

Costs Less

Submitting paper claims has costs that are not related to electronic claims. Even if you use a computer to generate the claims, you still have to buy envelopes, pay for postage, pay for claim forms and spend time preparing the claims and mailing them.

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Becoming an Electronic Submitter

Step 1

Obtain software for electronic submission of claims. There are several options available:

  • Utilize a software vendor’s product.
  • Write a software program utilizing the approved HIPAA ANSI X12N 837 format. More information is available in our guide, Standard Companion Guide Health Care Claim Professional (837P).
  • Employ a billing service or clearinghouse. If a provider chooses this option, Step 2 (applying for a sender number) is not required.
  • Download NGS’ HIPAA-compliant software program, PC-ACE. 

Step 2

Apply for a submitter ID, by completing the Enrollment Packet.

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PC-ACE

PC-ACE (NGS’ software program) is a free PC compatible software program with the ability to electronically transmit HIPAA-compliant claims, and MSP claims. By utilizing PC-ACE, HIPAA-compliant Medicare electronic claims are paid based on a 14-day payment floor versus a 29-day payment floor.

User managed tables contain vital information such as patient demographics, name, and facility name. These tables assist the user in creating claims quickly and accurately.

For complete details visit EDI Software: PC-ACE.

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EDI: Beyond Claims and Extra Features

The EDI environment has expanded beyond the submission of electronic claims.

Electronic beneficiary eligibility inquiry and response for Medicare is available to you. This is the HIPAA-compliant 270/271 transaction that allows you to access patient eligibility information, such as effective and termination dates, deductible, HMO information, and MSP data.

In addition, CMS offers real-time Internet-based eligibility transactions. These 270/271 transactions are processed through the CMS data center. Providers and clearinghouses must be authenticated by CMS before conducting these transactions. Telecommunications software is also required in order to access the CMS network. For more information, visit the HIPAA Eligibility Transaction System (HETS).

Providers sending claims electronically should utilize all EDI transactions.

NGSConnex

All providers submitting claims electronically are eligible for NGSConnex. With access to NGSConnex, providers are able to view the status of all claims as they appear in the NGS Medicare Part B claims processing system. This includes detailed information on paid, denied, and pended claims for electronically transmitted claims, paper claims, assigned and nonassigned claims. This information can be searched by viewing all claims for a specific provider number, using the Medicare patient’s MBI number or through a specific date or dates of service. Remittance advices are also available for viewing and printing upon required enrollment. Visit NGSConnex for details.

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Connectivity Alternatives/Network Service Vendors

NGS offers a list of approved network service vendors to provide a method of communication to EDI Services. These vendors offer services and benefits that include connection to NGS for submission and receipt of HIPAA transactions.

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Electronic Remittance Advice/Electronic Funds Transfer

The ERA is available several days sooner than mailed paper remittances. The ERA enables a provider to receive payment information on a daily basis, therefore preparing their office for a more efficient automated office management style. Providers with accounts receivable systems may have the ability to post payments electronically. Posting payments automatically can save the provider numerous hours in the office. NGS does not have or support automatic positing software.

NGS will automatically deposit claim payment into a checking or savings account as specified by the provider through EFT. Electronically deposited funds are available in the provider’s account the day after Medicare transmits an EFT to the bank. This eliminates the mail time it takes to receive a paper check as well as trips to the bank. EFT conversion will bring you completely into the EDI environment.

Providers that are not taking advantage of all EDI services listed above are completing unnecessary paperwork. Providers currently using a software vendor or billing service should contact them first to make sure their system has these capabilities. Visit EDI Enrollment for the information you need to enroll for ERA online or call the EDI Help Desk for additional information.

  • J6: 877-273-4334
  • JK: 888-379-9132

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Medicare Remit Easy Print Software

Are you still using the SPR? Save time and money by taking advantage of free MREP software now available for viewing and printing the HIPAA-compliant ERA. The MREP software gives providers and suppliers the following functions:

  • Easy navigation and viewing of the ERA using your personal computer
  • Print the ERA in the SPR format
  • Search capability that allows providers and suppliers the ability to find claims information easily
  • Print and export reports about ERAs including denied, adjusted and deductible applied claims, and
  • Easy-to-use method to archive, restore and delete imported ERAs

Providers and suppliers can view and print as many or as few claims as needed. This is especially helpful when you need to print only one claim from the remittance advice when forwarding the claim to a secondary payer. This free software saves time resolving Medicare claim issues. Take advantage of the MREP features unavailable with the SPR.

In order to utilize the MREP software, you will need to receive a HIPAA-compliant ERA. Visit About Medicare Remit Easy Print to learn more. Take advantage of this software, begin using MREP today.

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Administrative Simplification Compliance Act

The ASCA includes a provision that states, effective 10/16/2003; Medicare may not pay claims submitted on paper with certain exceptions. Some exceptions listed in the Final Rule are:

  • Small provider*
  • Dentist
  • Claims for Medicare demonstration projects
  • Providers that conduct mass immunizations
  • Tertiary claims
  • Claims for services rendered outside of the United States
  • Disruption in electricity and communication connections beyond the provider’s control
  • “Unusual circumstance” claims
  • Claims submitted by beneficiaries
  • A provider that submits fewer than 120 claims per year
  • Non-Medicare managed care organizations

* The definition of a Part B small provider is one with less than ten full-time equivalent employees.

View ASCA Requirements for Paper Claim Submissions for additional information.

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Contacting the EDI Help Desk

  • J6: 877-273-4334
  • JK: 888-379-9132

Available by phone or email Monday–Friday; 8:00 a.m.‒5:00 p.m. ET

Closed for training on the 2nd and 4th Friday of the month from 12:00‒4:00 p.m. ET.

The EDI help desk can also be contacted via email at NGS_EDI_PartB@anthem.com. When communicating via email, the EDI Help Desk is required to respond within 10 days.

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Revised 10/14/2024