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News about HIPAA-Compliant Electronic Claims

Bulletin (Mar 3, 2004)

EDIFECS certification was passed on February 20, 2004.

  

Testing Status (June 14, 2006)

HIPAA requires all covered entities who transmit claims (and other information) electronically to conform to a particular standard, called ANSI 837 4010A.  Unfortunately the standard is not standard--every payer can make up his own "business rules".  The rules are supposed to be negotiated with the submitters, but you just try negotiating with Medicare.

Claims may be submitted directly to the payer or through a clearinghouse.  Most commercial insurance companies require submission through a clearinghouse, but Medicare, Medicaid, and the Blues can be submitted directly, saving clearinghouse fees.

To submit claims directly, they must be tested separately with each and every payer. Medicare and Medicaid in particular have different processes in every state or region. This seems to be largely true of Blue Cross and Blue Shield, too.

This page will contain news about this process as we learn it, and about our progress...

  

 

AR Medicare Passed
AK Medicare Passed
AZ Medicare Passed
CA Medicare (Northern) Passed
CA Medicare (Southern) Passed
CA BC, BS Passed
CA Medi-Cal Passed
CA LA County Mental Health Passed
CO Medicare Passed
CT Medicare Passed
CT BC Passed
FL Medicare Passed for Basic, Surgery, Radiology
FL BCBS Passed via Availity
GA Blue Cross Same processor as CA
GA Medicare Passed
HI Medicare Passed
IA Medicare Passed
ID Medicare, BCBS, and Commercial In process. Via Blue Cross.
ID Medicare Passed NC, same processor (CIGNA)
IL Medicare Passed via WPS
IN Medicare Passed
IN BC Passed via Anthem
KY BC Passed via Anthem
KS Medicare (ASK) Passed
LA Medicaid Passed
ME BS Passed
MI Medicare Passed via WPS
MN Medicare Passed via WPS
MS Medicare Passed
NC Medicare Passed
ND Medicare Passed
NJ Medicare Passed via Empire and HGSA
NY Empire Medicare Passed via Empire BCBS
NV BC Passed via Anthem
OH Medicare Passed via Palmetto
OH BC Passed via Anthem
OR Medicare Passed
PA Medicare Passed via Highmark
SC Medicare Same processor as OH, but may have to test separately
SD Medicare Passed
TN Medicare Passed NC, same processor (CIGNA)
TX Medicare Passed for Medical/Surgical/OTH category. Via THIN (Availity).
TX Medicaid Passed via THIN(Availity).
TX Blue Shield Passed via THIN(Availity).
TX Commercial Passed via THIN(Availity).
WA Medicare Passed
WI Medicare Passed via WPS
WV Medicare Passed via Palmetto
WY Medicare Passed
Clearinghouses  
Electronic Technologies Inc Passed
Gateway EDI Passed
Inmediata Passed
Medavant Passed
THIN (now Availity) Passed.  Free!  Transmits BC or BS only for Texas.
Triple S In process