A step-by-step guide to getting started submitting electronic claims for third party entities

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Home ► Getting started ► A step-by-step guide to getting started submitting electronic claims for third party entities

Last Modified: 11/6/2024 Location: FL, PR, USVI Business: Part A, Part B

A step-by-step guide to getting started submitting electronic claims for third party entities

For clearinghouses, billing services, network service vendors and third-party vendors considering submitting claims via Electronic Data Interchange (EDI), the following information outlines procedures related to getting started.

1. Changing from paper to EDI: Evaluate your current office methods of paper claims submission.

• Computer-generated paper claims? If your office has a computer that is used to generate paper claims, and you maintain the services of a vendor who services your software and/or hardware, contact your vendor first. The vendor may have already developed electronic capabilities and could help you set up and get started billing electronically. In fact, your existing system may already possess electronic claim submission capabilities.

• Medicare’s free electronic claim submission software, PC-ACE is available free of charge if downloaded. You can also take advantage of other electronic applications such as the Electronic Remittance Advice and Health Care Claim Acknowledgement reports that will assist you in maximizing your office efficiency. All Medicare EDI Trading Partners submissions and retrievals are required to use a Network Service Vendor (NSV) for connectivity to the EDI Gateway. For a list of known (NSV’s) please visit “Getting Started with PC-ACE.” Specific services and financial arrangements must be made between the Submitter and (NSV).

• Handwritten or typed paper claims? If your office does not have a computer and you need to know where to start, refer to the article “Choosing a Vendor.”

2. Complete the proper form: Once you decide to submit claims electronically, you will need to complete the following form:

• EDI Third Party Enrollment form pdf file

• If you are requesting to be assigned a new submitter ID, you must indicate your software vendor. If the software vendor is not yet an approved software vendor with First Coast, the software vendor will need to submit the EDI Third Party Enrollment form for testing purposes only. Once testing is complete and passed, then you may submit the form to be assigned a submitter ID.

• Note: this form is only for clearinghouses, billing services, network service vendors and third party vendors. Providers will need to complete the “Electronic Data Interchange (EDI) enrollment form pdf file

” form.

3. Submit test claims: Once you have been assigned an EDI sender/submitter number you will be required to submit a batch of test claims (from your office to our office not the vendor location), for evaluation. The Medicare EDI testing area will evaluate the test and contact you with the results. The test must meet accuracy requirements to be approved to submit production electronic claims for processing.

Test claims do not need to be new claims. If you are unable to collect enough new claims for a test, you may use claims that have already been processed. Your test is submitted into a separate testing system and is not processed for payment.

You should receive the test results within three working days from the date the test data is received by First Coast EDI.

4. Submit production claims: Upon approval to submit production claims (passed the test), you may begin submitting claims electronically in the production environment for any providers setup to have claims sent to First Coast through your company. Claims will need submitted within 30 days to establish the required connection. We request that you transmit at least one production batch per month to keep your sender number and password active.

5. Retrieve reports: The 999 initial acknowledgement and 277CA reports after each 837 claim file submission to ensure the file was accepted. You can take advantage of other electronic applications that will assist you in maximizing your efficiency. These applications are listed in the order of provider needs.

• Initial Acknowledgement (999)

• Electronic receipt of claim submission (Health Care Claim Acknowledgement) (277CA)

• Electronic remittance advice (ERA) (835)

• Electronic claim status (ECS) (276/277)

If you have any questions concerning “Getting Started Steps” or other electronic applications, contact Medicare EDI at 888-670-0940.

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