Electronic Media Claim Submission (EDI and Single Claim Submission)
New Transaction and Code Requirements
Under the Health Insurance Portability and Accountability Act (HIPAA), all covered entities must switch to the new transaction and code standards effective October 16, 2003. Technical instructions, Implementation and Companion Guides for these electronic transactions can be found on the ValueOptions® Web site at www.valueoptions.com. In using this system, ValueOptions® and providers must:
- (i) Not change any definition, data condition or use of a data element or segment as proscribed in the Health and Human Services (HHS) Transaction Standard Regulation. (45 CFR 162.915(a)).
- (ii) Not add any data elements or segments to the maximum defined data set as defined in the HHS Transaction Standard Regulation. (45 CFR 162.915 (b)).
- (iii) Not use any code or data elements that are either marked “not used” in the HHS Transaction Standard’s implementation specifications or are not in the HHS Transaction Standard’s implementation specifications. (45 CFR 162.915 (c)).
- (iv) Not change the meaning or intent of any of the HHS Transaction Standard’s implementation specifications. (45 CFR 162.915 (d)).
The Single Claim Submission feature is a web-based method of submitting one (CMS-1500) claim at a time to ValueOptions®. This method of submitting claims is recommended for a small provider office that would submit no more than 20 claims at a time.
EDI Claims Link for Windows is an electronic claim submission process developed by ValueOptions® and is free to providers who wish to submit electronic claims to ValueOptions®.
ValueOptions® will accept the following HIPAA compliant claim files:
- Files programmed by the Provider’s IT Department;
- Files submitted using ValueOptions’® EDI Claims Link for Windows software;
- Claims submitted using ValueOptions’® Single Claim Submission process. Note: Please see the ValueOptions® Provider Guide to using Single Claim Submission, available on the www.valueoptions.com website, under “Providers”
The following information is required from the provider prior to submitting claims electronically:
- Completed Account Request Form
- Intermediary Authorization Form (if using a billing agent or clearinghouse)
- Files must be HIPAA compliant (if using EDI Claims Link for Windows software, this software is HIPAA compliant)
- Must submit a test file to verify accurate information is included in the file
