Electronic Transactions

Billing

Billing and EDI Authorization and Set-Up Form
Form to be used for direct deposit, electronic voucher 835/ERA, and billing services/clearinghouses


Electronic HIPAA Eligibility Benefits Inquiry and Response 270-271

The Health Plan provides the ability for a practitioner/facility to submit a file for eligibility information and benefits for our members (HIPAA Eligibility Benefits Inquiry and Response 270-271) through their designated clearinghouse or directly to their office as instructed. To establish a connection for the 270/271, please contact your clearinghouse in regard to setting up the ability to submit and receive the electronic eligibility and benefits inquiries with The Health Plan. Your clearinghouse will contact The Health Plan directly and advise them when to begin sending the electronic vouchers. If you currently are not utilizing a software vendor contact our EDI Support Center for alternatives.

The Health Plan criteria for the 270/271:

  • Member must be active on the search date that is in the file, or if not present then active on the current date.
  • HP search is on the Member Number and suffix number. (Found on Member ID card)
  • HP search is on the Member Number, first name, and date of birth.
  • HP search is on the Medicare HIC number.
  • HP search is on the Medicaid ID number.
  • HP search on the last name, first name, gender, and date of birth.

The Health Plan provides the HIPAA 835 transaction set for electronic vouchers. The electronic vouchers are produced with all lines of business on a daily basis as payments are released. Self-Funded payments are released at the direction of the self-funded employer group administrators. The Commercial, Medicare Advantage, WV Medicaid, and PEIA are released on Wednesday mornings for providers and on Friday mornings for facilities.

If you are currently utilizing a clearinghouse or a registered submitter to The Health Plan, simply contact your submitter/clearinghouse to set up the retrieval of the electronic vouchers for your organization. The list of trading partner/clearinghouses provides the payor ID.

If you are NOT currently using a clearinghouse or registered submitter for The Health Plan, please complete a Trading Partner Form and email it to the EDI Support Center at hpecs@healthplan.org. Once received, The Health Plan will set up the electronic voucher to be sent to your designated location by Internet or FTP. The set up information will include file names, submitter ID, sign on and password for Internet or FTP. Download our preferred clearinghouses.

Provider/facilities set up for ERA electronic vouchers will continue to receive their paper vouchers for six months after the receipt of three successful ERA. If you wish to extend the standard six months, please notify the EDI Support Center in writing. We also have a form available for these requests. Paper vouchers will be discontinued for existing provider/facilities unless a request for an extension is received.

If files or reports are missing or requiring status, the clearinghouse or submitter is to contact the EDI Support Center via email with all details to assist in their location. Responses for these emails will be within 24 to 72 business hours in most cases.

Also, if you receive electronic vouchers successfully, we can discontinue the mailing of paper vouchers. The vouchers are placed on the Secure Provider website for download and you can access and download the vouchers at your convenience.


Electronic Claims Resubmission

Resubmission of claims can now be received electronically. Using the claim frequency type code, also known as the claim submission reason code. Place the code "7" in the Claim Information 2300 Loop Segment CLM05.

Claims received electronically with the code "7" will be processed as a resubmitted claim. If any other number is placed in the CLM05 segment, the claim will be processed as a new claim and could result in a duplicate claim denial. Continue to follow the established Health Plan guidelines for resubmission of claims. The resubmission guidelines can be found in the Provider Procedural Manual. To provide additional information for electronic resubmitted claims, please fax the documents to our designated fax at 740.695.7882, using the cover sheet provided in our Provider Procedural Manual, Section 9.

Submitting an Electronic Claim

The Health Plan currently accepts claims in the HIPAA 837 5010 format for both professional and institutional claims. We also will accept claims submitted for the 1500 professional claims through our website. We do not have a payor number. A payor number is a number utilized by a clearinghouse to designate a payor. We accept claims direct at no cost and assign a user ID and password at the time of testing. We currently do not pay to receive claims. There are several clearinghouses that charge the payor for the receipt of claims.

We have accepted claims from several clearinghouses successfully for years. We do not recommend any particular clearinghouse, but we can provide names of some of the companies we have been receiving claims from. Our EDI support staff will work directly with your staff in setting up and submitting a "Test" file of claims in a secure format. We request at least 10 claims examples, representing each type of file being tested. Your staff will contact our staff once a Test file(s) has been submitted to The Health Plan. Our EDI support staff will evaluate and be in direct contact with your staff in regard to the file(s). The evaluation and response is within two business weeks based on volume of files.

The Test file will be processed supplying a HIPAA 9999 notice or any prearranged reporting. Upon a successful TEST file, you can begin immediately to send your claims. A HIPAA 999 notice will be sent to you on the day of receipt and we also provide a detailed report of each claim as a courtesy within 24 to 48 hours. These reports are sent to the submitter of the claims, not the provider, unless they are one in the same. A HIPAA 277CA will be released within 24 to 48 hours, as well. If files or reports are missing or requiring status, the clearinghouse or submitter is to contact the EDI Support Center by email with all details to assist in their location. Response for these emails will be within 24 to 72 business hours, in most cases.

A Trading Partner Agreement must be completed by you or your clearinghouse prior to submitting a Test file.


Electronic Remittance

The Health Plan provides the HIPAA 835 transaction set for electronic vouchers. The electronic vouchers are produced with all lines of business on a daily basis as payments are released. Self-funded payments are released at the direction of the self-funded employer group administrators. The Commercial, Medicare Advantage, WV Medicaid, and PEIA are released on Wednesday mornings for providers and on Friday mornings for facilities.

If you are currently utilizing a clearinghouse or a registered submitter to The Health Plan, simply contact your submitter/clearinghouse to set up the retrieval of the electronic vouchers for your organization. The list of trading partner/clearinghouses provides the payor ID. If you are NOT currently using a clearinghouse or registered submitter for The Health Plan, please complete a Trading Partner Form and email it to the EDI Support Center at hpecs@healthplan.org. Once received, The Health Plan will set up the electronic voucher to be sent to your designated location by Internet or FTP. The set up information will include file names, submitter ID, sign on and password for Internet or FTP.

Provider/facilities set-up for ERA electronic vouchers will continue to receive their paper vouchers for six months after the receipt of three successful ERA. If you wish to extend the standard six months, please notify the EDI Support Center in writing. We also have a form available for these requests. The paper vouchers will be discontinued for existing provider/facilities unless a request for an extension is received.

If files or reports are missing or requiring status, the clearinghouse or submitter is to contact the EDI Support Center via email with all details to assist in their location. Responses for these emails will be within 24 to 72 business hours in most cases. Also, if you receive electronic vouchers successfully, we can discontinue the mailing of paper vouchers. The vouchers are placed on the Secure Provider website for download and you can access and download the vouchers at your convenience.