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Login to Electronic Transactions.
The Electronic Transactions section includes the following:
The Electronic Commerce (EC) team, through a variety of products and offerings, works with providers to develop, enhance and support electronic transactions, including electronic claims, eligibility, claim status, referrals, provider number inquiry and electronic provider remittance advice (EPRA).
The EC team also supports the transactions and initiatives for Medica to be in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Compliance is dependent upon implementing standards in the health care industry where electronic exchange of data occurs. To accomplish this, most payers, including Medica, will use the ANSI ASC X12N standards, version 4010 as adopted by HIPAA.
Go to Minnesota HIPAA Collaborative Web site for more information.
Medica encourages the use of electronic transactions and electronic claim submission whenever possible. Medica is committed to evaluating and pursuing multiple options for electronic transaction processing for our providers. We are actively exploring alternatives in the marketplace, including our own development efforts, which will allow providers to choose from a variety of options to submit electronic claims.
The Medica EC team is available to answer questions and consult on electronic transaction options. They are also available to troubleshoot issues with electronic claim submission, error reports and other connectivity issues. The EC team can be reached by sending an e-mail to medica.electroniccommerce@medica.com.
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Medica Electronic Commerce supports a variety of tools for electronic claim submission, as well as other real-time transactions, such as eligibility and claim status.
Several product offerings can be incorporated into an existing Accounts Receivable or Practice Management system already in place within the provider’s office. By embedding EDI transactions within the provider’s existing system, a vendor interface increases cost savings through expanded transaction capabilities, reduces staff hours, and streamlines efficient processes.
A vendor interface may connect to a clearinghouse to submit transactions to a variety of payers. The clearinghouse then routes claims and other transactions for many payers to the appropriate destination. Or a vendor interface may use other connectivity mechanisms, such as an Internet application, to submit transactions electronically.
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Medica has its own payer I.D. for electronic claims submissions. To route claims electronically, please use the Medica Payer I.D. 94265.
For further information on the ANSI 837 Claim transaction or to obtain the implementation guide, visit the Washington Publishing Web site.
View Medica Electronic Claim Flow.
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Electronic claim submitters receive a variety of submission reports to confirm successful submission of claim files and notification of errors or claim rejections. Providers must correct and resubmit claims that are rejected or in error in the EDI submission process. Rejected claims are not available for adjustment. Claim submission reports act as a receipt for electronic claim submission. We strongly encourage providers to review all reports, because they are responsible for verifying their own claim submissions and correcting rejected claims within timely filing limits.
Generally speaking, claim reports are returned to the submitter using the same channels as electronic claims. Time frames for receiving these reports typically are 24 hours to three business days.
Your Practice Management or Claim Submission vendor can help you identify and understand the claim submission reports you will receive.
| Social Security/employee number not on carrier files | - Verify the correct Medica ID#. Eligibility information is available via WebMD Office, Claimlynx, B2B, etc.
- Contact the enrollee to obtain the current insurance information.
| | No coverage for the type charges submitted | - Verify Medica liability for the date of service. Eligibility information is available via WebMD Office, Claimlynx, B2B, etc.
- If the patient is the subscriber, verify the Patient Relationship to Insured field is “self” and the Insured Name field is the patient name.
| | Insured name/address does not match carrier files for SSN/Insured ID | - Verify that you are submitting accurate information in the Insured Name field. The insured’s name must match our eligibility files. (Situations to keep in mind: Has the member recently married? Is their last name hyphenated? Does the child have a different last name than our member?).
- Verify that you are submitting accurate information in the Insured Address field. The insured’s address must match our eligibility files.
| | Coverage has been cancelled for this insured | - Verify eligibility for dates of service. Eligibility information is available via WebMD Office, Claimlynx, B2B, etc.
| | Claim returned to provider, no further updates to follow | - You will receive no further electronic updates. However, the claims processing site will be following up with a letter of explanation as to why they were not able to process this specific claim.
- The letter is sent to the billing address submitted on the claim.
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Electronic Provider Remittance Advice (EPRA) is another HIPAA transaction supported by the EC team. By receiving EPRA, the provider has the opportunity to reduce staff hours by automating the account posting process. Receiving EPRA tightens the circle for a completely automated claims process.
The v.4010A1 file is routed to either ENS or United Healthcare’s B2B for distribution to the provider.
Providers then use the EPRA file to automatically post payments into their Practice Management System. At this time, only remittance files are sent electronically--Electronic Funds Transfer (EFT) is not available.
Some EPRA receivers continue to receive paper remittance as a backup and audit trail. Recipients of EPRA files are solely responsible for ensuring that appropriate audit and accounting practices are in place within their organization to handle automated posting.
To receive EPRA files, connectivity either with ENS or United’s B2B must first be established. Often, the provider’s Practice Management Systems vendor will obtain this connectivity to facilitate receipt of files and accommodate automated posting of accounts. Once connectivity is in place, complete the necessary registration forms at your vendor or clearninghouse. The vendor or clearinghouse will send the necessary registration forms on to their business partners in order to complete the set up process. To facilitate automated posting, providers are encouraged to work with their systems vendor or internal systems staff to make any needed updates to their Accounts Receivable system. Many vendors charge for these updates and ongoing maintenance.
Whenever possible, the electronic remit will mirror the paper remit. However, there are instances when this is not possible. Because the EPRA file is formatted as an ANSI transaction, the disallow and denial codes on the EPRA are as mandated within the ANSI X12 835 Implementation Guide. Therefore, the disallow/denial codes on the electronic remittances are not identical to those found on paper remittances. For a cross-reference guide to the disallow and denial codes used on both the paper and electronic remittances, view Disallow Denial and Adjustment Code List.
View EPRA HIPAA Compliant Flow Chart.
For further information on Provider Remittance, go to Interpreting the Provider Remittance Advice. Return to top
Providers are able to obtain additonal information, including downloadable forms, under the Electronic Commerce section of General Tools and Forms.
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Return to Billing and Reimbursement. |
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