Legion Healthcare Solutions

Understanding Basics of EDI Enrollment

Understanding Basics of EDI Enrollment

Basics of EDI Enrollment

The introduction of the electronic claim submission process has changed medical billing and the overall healthcare industry forever. The system of paper claim management was filled with inefficiencies and inaccuracies. For providers looking to eliminate these problem areas in their claims process, EDI enrollment is necessary. Electronic Data Interchange (EDI) is an innovative digital communication tool that is used to deliver data from a provider to a payer. In order to be eligible to submit electronic claims to private or government payers, providers must complete EDI enrollment.

Until you have completed all necessary registration processes, you won’t be able to submit electronic claims to that insurance agency. While some payers are still accepting paper claims most of them won’t allow the submission of paper claims at all. In a perfect world, providers would only have to complete a few documents and distribute them to all payers, but this is not the case. Providers work with dozens of insurance companies who each have their own list of requirements. It becomes obvious that EDI enrollment quickly becomes overwhelming to a healthcare organization that works with more than one or two payers. Each insurance carrier has different procedures and requirements to qualify for EDI. Note that before registering for EDI enrollment, you have to complete all steps in the provider enrollment process.  

EDI Enrollment and Medicare

The Centers for Medicare & Medicaid Services (CMS) standard Electronic Data Interchange (EDI) enrollment form must be completed prior to submitting Electronic Media Claims (EMCs) or other EDI transactions to Medicare. The agreement must be executed by each provider of health care services, physician, or supplier that intends to submit EMC or use EDI, either directly with Medicare or through a billing service or clearinghouse. Each new EMC biller must sign the form and submit it to their local Medicare Administrative Contractor (MAC) or Durable Medicare Equipment (DME) MAC. Any healthcare organization comprising multiple components that have been assigned Medicare provider numbers, supplier numbers, or UPINs may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which these numbers have been assigned. The organization as a whole is held responsible for the performance of its components. You can refer the Medicare Claims Processing Manual (Pub.100-04), Chapter 24, and Sections 30 – 30.4 for detailed information.

Top EDI Application Errors

While working with various providers, we observed the following top EDI application errors:

  • Application submitted without the Group PTAN: Accurately list your group PTAN and NPI along with the individual PTAN and NPI
  • Duplicate application requests: This may happen when you submit a new application while the previous one is under process. Please allow at least 20 business days for processing the application.
  • Incomplete applications or agreements: Fill in all the relevant areas on the application form.
  • Invalid PTAN or submitter ID listed on EDI application: A Submitter ID number is a unique number identifying electronic submitters. EDI applications cannot be processed without a valid PTAN and Submitter ID
  • No signature attached: EDI applications cannot be processed if the signature page is not completed or missing.

Accurately Submitting EDI Application

Even though each payer has their unique application form, the following guidelines would be helpful in accurately submitting an EDI application:

The EDI enrollment form should be submitted when enrolling for electronic billing. You need to complete the provider enrollment procedure prior to filling EDI enrollment application.

  • Please ensure that you include your Medicare Provider Number and National Provider Identifier (NPI) where requested on the EDI Enrollment Form.
  • If the submitter will be submitting for multiple providers, this form must be completed by each provider whose claim data will be submitted. If a provider is a member of a group, only one agreement per group is required.
  • EDI applications should be reviewed and signed only by the providers to ensure each provider is knowledgeable of the enrollment request and the associated requirements. You must notify payers in case of any changes in their billing agent or clearinghouse. Also update payers the effective date of which the provider will discontinue using a specific billing agent or clearinghouse.
  • Providers that have contracted with a third party (clearinghouse/network service vendor or a billing agent) are required to have an agreement signed by that third party in which the third party has agreed to meet the security and privacy requirements that apply to the provider.

Legion Health Care Solutions is a leading medical billing company that can assist you in revenue cycle functions for your practice. We can assist you in completing all processes required for electronic claim submission including EDI enrollment for all applicable payers. To know more about our provider credentialing & enrollment services, contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com

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