Frequently asked questions about EDI

When you submit claims electronically, you will:

• Streamline administrative tasks;
• Save time and money because electronic (EDI) claims process faster and more accurately than paper claims;
• May be able to receive an 835 (electronic) remittance advice from us should you be set up properly, and choose to do so.

Participating and non-participating providers can send claims to WellSense electronically if they meet any one of the following criteria:

• They can produce claims in HIPAA-compliant 837 format.
• They use a billing agency that can produce HIPAA-compliant 837 files.
• They use one of the clearinghouses listed below (or a clearinghouse or billing agency that uses one of the clearinghouses listed below).
• They submit claims via the New England Healthcare EDI Network (NEHEN).

If a provider already sends electronic claims to another insurance plan, chances are that the provider can also send claims to WellSense. At this time WellSense does not have functionality on its Web site to accept claims or issue claims submission software for provider use.

NOTE: The provider’s NPI must be on file at WellSense. Claims submitted with NPIs that are not registered at Well Sense Health Plan will be rejected. If a non-participating provider or a new doctor at a participating provider practice has an NPI that is not registered at Well Sense Health Plan, that provider should contact his or her assigned Provider Relations Consultant, call our Provider line at 877-957-1300 (option 3) to register the NPI, or click here to submit the NPI information directly.

A clearinghouse is a company that takes claims information from any doctor, hospital, etc., and sends claims on their behalf to “payers” (e.g., insurance companies like Blue Cross Blue Shield) on paper or as electronic files. Large clearinghouses have many subsidiaries, usually billing or claims companies that they have bought. For instance, Emdeon (formerly known as WebMD) bought Envoy, which used to be the biggest clearinghouse. Emdeon also bought Medical Manager, a company that produces software many doctors use to send electronic claims. We have active relationships with the largest clearinghouses in America: Emdeon (also known as WebMD, NEIC, Envoy, HealthWire, Medical Manager, and by other names), The SSI Group, Capario (formerly known as MedAvant, ProxyMed, MedUnite and NDC), RelayHealth (comprising McKesson and Per-Se), Gateway EDI, and Allscripts/Payerpath.

Clearinghouse	WellSense Health Plan's Payer ID
Emdeon	13337
Capario	13337
RelayHealth	Professional claims: 3818 Institutional claims: 2921
The SSI Group	13337
Gateway EDI	13337
Allscripts/Payerpath	13337

Most other clearinghouses have relationships with one of these clearinghouses, so even if a provider office does not work directly with one of the above, Well Sense Health Plan should still be able to receive electronic claims through your relationship with that other clearinghouse. For instance, WellSense also works with GE Healthcare/IDX Systems and MedAssets.

Basically, billing agencies are “middle men” between providers (e.g., doctors/facilities) and clearinghouses and/or payers. Billing agencies create claims for providers using the information the provider sends to them. Billing agencies often give providers software to use to send the claims information to them. Many billing agencies then send paper or electronic claims to clearinghouses, although some send claims directly to payers (e.g., insurance companies).

An 837 is a certain kind of electronic claims file that HIPAA requires providers to use to submit claims electronically. There are some older forms of the 837 file, but HIPAA requires that health plans and EDI submitters use the latest version, called “X12N 837 version 5010.” (5010 was mandated for use in January 2012, with full compliance slated for July 1, 2012; see Question 8 below for more information.) There are very specific rules about what kind of information can go in an 837 and exactly where that information should be put. Doctors who bill using the paper CMS-1500 form would use an 837P (the P is for professional) format; hospitals and facilities that use the paper UB-04 form would use an 837I (the I is for Institutional). Most doctors can’t produce 837 files directly, so if they want to send electronic claims, they must use a clearinghouse or billing agency that can produce the 837 files for them. The current HIPAA-compliant 837 file format has these numerical designations:

837P: 005010X222A1
837I: 005010X223A2

There are several alternatives for submitting claims to the WellSense:

Providers can send claims directly to WellSense. If a provider produces claims in an 837 format or uses a billing agency that can produce claims in an 837 format, WellSense can receive those files directly. This will probably be the most cost-effective way to submit claims to WellSense since clearinghouses tend to charge fees that vary based on the number of claims submitted on a provider’s behalf.

Providers can send claims through NEHEN and NEHENNet to WellSense. NEHEN subscribers should contact their NEHEN Technical Support representative to request setup.

Providers can submit claims to WellSense through a clearinghouse or billing agency. The SSI Group, Capario, Emdeon, RelayHealth, Gateway EDI, Allscripts/Payerpath or one of their subsidiaries can send claims files in the required HIPAA-compliant 837 format to WellSense on a provider’s behalf; billing agencies offer the same service. To get set up, providers should contact their representative at the clearinghouse or billing agency for instructions. WellSense payer IDs for each clearinghouse are listed in above.

At this time WellSense cannot accept claims online or issue claims submission software for provider use.

WellSense can receive electronic claims directly from a provider or the provider’s billing agency, instead of via a clearinghouse, and this method should be less costly for the provider since clearinghouse fees tend to vary based on the number of claims processed on a provider’s behalf, and because the Plan charges no fees for direct submission. To send claims directly to the Plan, the provider or its billing agency must be able to produce a HIPAA-compliant 837 file, have an Internet connection (to transmit the claims files), and have either Secure FTP software (e.g., FileZilla) or PGP encryption software to satisfy HIPAA Privacy/Security regulations. Providers or billing agencies interested in submitting claims directly to WellSense should contact us at 617-748-6175 or see the EDI Claims Companion Guide.

At this time WellSense cannot accept claims online or issue claims submission software for provider use.

The federal government mandated that all electronic health care transactions conform to the new 5010 standards as of January 12, 2012, with compliance enforced as of July 1,2012. Well Sense Health Plan is processing claims (837), electronic remittance advices (835), and eligibility requests (270/271) in 5010 format. Providers/EDI submitters wishing to test 5010 transactions or to get more info can contact us at 617-748-6175.

WellSense rejects initial claims submissions only for three reasons: unrecognized member IDs, unrecognized NPIs (i.e., mis-typed NPIs or NPIs not registered at Well Sense Health Plan), or a pay-to tax ID that doesn’t match the pay-to tax ID Well Sense Health Plan has on file for the submitted NPI. For electronic claims, those IDs/NPIs must be in certain locations in the 837 files with certain qualifiers. We often find that a provider’s software shows the correct IDs/NPIs on the screen, but the 837 file that we receive from the clearinghouse has the IDs/NPIs in the wrong location or with the wrong qualifier. For corrected claims there are additional criteria that must be satisfied to prevent a claim from rejecting.

There are two electronic ways for providers to check whether a member is eligible for services at Well Sense Health Plan:

• Using WellSense Health Plan’s Web Services (login required).
• Using the HIPAA standard 270/271 transactions directly with the Plan or through any of the following partners: NEHEN, Gateway EDI, Passport Health, TransUnion (formerly MedData) and HDX/Siemens.

After receipt of an electronic claims file, WellSense provides an Initial Claim Status report (sometimes referred to as a scrubber or error report) the next business day. This report shows whether each claim was accepted for processing or rejected. The only time an initial electronic claim will not make it into the Plan’s system is if the provider has used an unrecognized NPI, an unrecognized member ID, or a pay-to tax ID that doesn’t match the pay-to tax ID WellSense has on file for the submitted NPI. Providers can also check on the status of claims they’ve submitted by logging into the online portal site (if they’re participating providers) or calling our provider line at 877-957-1300 (option 3). Providers who don’t have a login to the online portal should contact their Provider Relations Consultant or call the provider line at 877-957-1300 to obtain one. All providers sending electronic claims MUST submit with the claim and NPI that is registered at WellSense AND a valid member ID or the claim will reject from our system.

You can check the status of a claim 24 hours a day, seven days a week using the secure claims status inquiry interactive tool that is part of the Plan’s Provider Web Services. If you don’t already have a login, contact your Provider Relations Consultant or call the provider line at 877-957-1300 (option 3).

In addition to determining the status of a claim, you can streamline your administrative tasks by using WellSense Web e-Services to:

• Run online reports such as member panel and redetermination reports;
• Verify member eligibility; and
• Look up policy and code information.

Providers can submit corrected claims electronically using the 837 format, but there are very specific rules for doing so that are required by the 837 format, and outlined in our EDI Claims Companion Guide on pages 17 and 18. Basically, corrected claims are submitted electronically as “replacement claims,” which have frequency codes of 7. UB-04 submitters are familiar with frequency codes from Form Locator 4, but frequency codes are not part of the CMS-1500 form, having been introduced in the 837P electronic file. A replacement claim asks the insurance company to take a specified claim received earlier and replace it with newly submitted information. Corrected claims must meet additional criteria to be accepted: they must include an original Well Sense Health Plan claim number in a finalized status, and the member ID and NPI must be the same on the corrected claim and the original claim.

Here’s a simplified example:

• A provider sends a claim to WellSense in January with three line items and a total charge of $250.
• WellSense gives the claim an ID of E99306842700 and pays the provider $250.
• In February the provider realizes the claim should have had five line items and a total charge of $400.
• The provider submits an electronic claim with a frequency code of 7, referencing the original claim ID of E99306842700, and showing all five line items (not just the two new line items).
• WellSense processes the replacement claim, assigns a new ID of E99306842701 and pays the claim.

No. Providers can still send paper claims. However, submitting claims electronically allows for faster turnaround of and greater accuracy in claims payment. Also, if a provider is billing for a service that requires an invoice or attachment (e.g., durable medical equipment, COB claims), those claims should not be sent electronically. Please note that paper claims will also be rejected without an NPI registered at Well Sense Health Plan.

Providers who submit electronic claims to WellSense can get electronic remittance advices, also known as 835s, which is the HIPAA name for the electronic file. Providers whose claims go through the following clearinghouses can get 835s through those clearinghouses: Allscripts, Gateway EDI, MedAssets, RelayHealth, and The SSI Group. Providers using other clearinghouses can have an 835 sent directly to them by calling us at 617-748-6175. Some billing agencies also return 835s to their clients; providers can check with those agencies. In addition to electronic remittance advices for electronic submitters, paper remittance advices are sent to any providers receiving payments unless the provider has asked not to receive them on paper; PDF versions of the paper remittance advices are also available on the Plan’s website. Providers who submit electronic claims directly to us and who want to get 835s should contact us at 617-748-6175. Providers who do not wish to receive the paper remittances can contact their Plan Provider Consultant or call 617-748-6175.

Providers can download a copy of our Companion Guides, which outline our testing procedures and communications setup and gives Plan-specific information about creating and reading HIPAA EDI files. Providers can also call us at 617-748-6175.