EDI Enrollment
Webinar
for Practice Insight Authorized Resellers
Martha Johnson, Dir. Of Payer Development
Donna Anderson, Supervisor of EDI Enrollment
Jes Wettstein, EDI Enrollment Specialist
Jessica Moran, EDI Enrollment Specialist
Topics we will cover…

EDI Enrollment- What IT IS, What IT IS NOT

Profiling your Customer

Managing the EDI Enrollment Forms
(Claims/ERAs)

Tracking EDI Enrollment Requests

Avoiding EDI Enrollment Problems (Delays!)

Enrolling your customer for Real-Time Eligibility
EDI Enrollment:
What IT IS, What it IS NOT.

EDI Enrollment IS:
a request by the provider made to a payer to allow
the exchange of specific EDI transactions with that
payer. The provider is already known to the payer.

EDI Enrollment IS NOT:
credentialing or registering the provider’s NPI# or
Tax ID # with the payer.
5 Types of ANSI Transactions

837 – Claims

835 – Remittance Advice (ERA)

270 - Eligibility Request

276 – Claim Status Inquiry

275 – Attachments (paperwork)
Profiling Your New Customer
Good questions to ask:

Single office or CBO?

Sharing Tax ID# with hospital or other office?

How many billing NPI#s tied to the Tax ID#?

For each payer, does the provider bill as a group
or are the individual providers billing “solo”?

Professional claims and/or Institutional claims?
Profiling Your New Customer
First things first!

Login to EDIinsight

Add the NEW CUSTOMER ACCOUNT

Get the basics input to the account:

Name, Address, Tax ID#
Profiling Your Customer

Add the Provider Records in EDI Customer
Account:

Provider Name, Address

Person or Non-Person?

Billing or Rendering?

NPI#

Tax ID#

Taxonomy (Specialty) Code

Medicare PTAN#, Medicaid ID#
Profiling Your Customer…
Create a Payer Inventory List

Build a list of your Customer’s Top Payers

Make a list of government payers your
customer needs: Medicare Part A/B, DMERC,
Medicaid, BCBS, Railroad Medicare, Tricare

Make a list of commercial payers your
customer needs: Aetna, CIGNA, Humana,
United Healthcare, commercial Medicaid
Managed Care plans (MCO)
Profiling Your Customer
Create a Payer Inventory List

Build a list of Payers that currently send Electronic
Remits to your Customer.


Note how each ERA is delivered to your Customer:
Clearinghouse, Provider/Web Portal, other direct
delivery to Customer
Add to the list any additional Payers from which
the Customer would like to have Electronic
Remittance files.
Profiling Your Customer
Create a Payer Inventory List

Compare the inventory list to the Practice
Insight payer list and look for gaps.

Pay attention to Professional vs. Institutional.

If payer is not found, contact us with your
request, including payer ID# (log an Issue or
email: enrollment@practiceinsight.net).
Time to Play
Whose Enrollment is it
Anyway?
Name / Describe 2 types of ANSI transactions
that we have discussed.
837 (Claims), 835 (ERAs), 270 (Eligibility),
275 (Attachments), 276 (Claim Status)
Whose Enrollment is it Anyway?
What should you do BEFORE your customer
submits any EDI enrollment paperwork to
payers?
Set up customer in EDIinsight.
Add customer and provider record(s).
Whose Enrollment is it Anyway?
What is a good question you can ask your new
customer to learn about how they file claims?
Single Office or CBO? Do you share tax ID #
with another office? How many billing NPI #s in
your office? Do your providers bill as a group or
as individuals, and for which payers? Do you bill
professional, institutional or both?
Where are the forms?
Web page where Practice Insight keeps library of EDI
enrollment documents:
http://www.practiceinsight.net/RESELLER_Docs/Enrollment.html
(This site is for Resellers, not Providers!
Go ahead and bookmark this URL.)
Fill Out EDI Enrollment Forms for
Each Billing Provider

Who is the Billing Provider for this Payer?





What NPI# is used to bill this Payer, e.g, group NPI#
or individual provider’s NPI#?
Is there more than 1 Billing Provider/NPI?
Address should match credentialing at Payer
Signatures must be Authorized
If any question about how the Customer is billing
the Payer, CALL the Payer and Ask!
Fill Out EDI Enrollment Forms
Electronic Remits

Payers typically deliver ERA files to one trading
partner only at a time—no duplicate delivery

Once enrolled, Payer will send ERA files for all
payments, whether the claim was submitted by
Practice Insight or not

Changing existing ERA authorization may require
additional LOA (letter of authorization) on provider
letterhead—check PI instruction page

ERA delivery to EDI Customer account depends on
complete and accurate input of provider Tax ID and
NPI numbers
What if I don’t find forms?
Government Payers

No forms? Contact enrollment department.



Govt. Payers require 6-10 weeks to develop a
new direct connection and approval to submit
claims or a new transaction type.
Electronic Remits must also be developed or
contracts negotiated for Practice Insight to
register and deliver these files
Questions? Create an issue.
**Distinguish between Professional vs. Institutional
Example: Medicare Part A and Medicare Part B
PI may need to test with Medicare Part A “Institutional”
Managing the EDI Enrollment Forms

Always download a current set of payer
enrollment forms (Refer to Reseller Docs URL)

Distribute Forms to Customer (Do not give out
URL)

Ideal time frame- 30 days before the go-live
date (forms do change)

Always check PI instructions for how to deliver
forms

Always make a copy of the completed
enrollment form
Tracking EDI Enrollment Requests

PI will share with Reseller any Payer
confirmations or rejections (usually by
email)

Some payers send NO notification to
Practice Insight or to the provider

Reseller can follow-up with payer

Call with your copy of forms in hand—Payers
often ask for Provider NPI, Tax ID or legacy
PIN
Time to Play
Whose Enrollment is it
Anyway?
What instructions should you refer to when
completing and submitting EDI enrollment forms?
The “Practice Insight” instruction page that
precedes each set of EDI Enrollment Forms
posted to the PI Reseller Forms’ Library.
Whose Enrollment is it Anyway?
If the Customer’s Go-Live date is February 1st,
what date should you target to send completed
forms to the payers?
January 1st. Allow approx. 30 Days.
Enrollment varies from payer to payer. (ERA
setups can take longer, 4-6 weeks.)
Whose Enrollment is it Anyway?
When following up on an EDI enrollment
request, what should you have in front of you?
Copy of the completed forms submitted to the
payer. It’s also helpful to know the date the
request was submitted.
Avoiding EDI Enrollment Problems
Top 5 Rejections
(From Payer):





Enrolling w/ wrong PTAN
(Individual vs. Group)
Provider Not Credentialed
Unauthorized Signature
Missing PTAN, Legacy, etc.
Didn’t Select Change CH
Top 5 “Action Needed”
(From Practice Insight):





Missing Signature
Missing NPI or TAX ID
Nothing Selected on
Form
Missing Valid Billing
Address
Illegible
Avoiding EDI Enrollment Problems

Always download the latest documents

Assist your customer

Proof read NPI numbers and Tax ID
numbers

Make sure no missing signatures
Enrolling your Customer for
Real-Time Eligibility
Payers that DO require Eligibility Enrollment:

CMS Medicare including all Medicare A/B,
Railroad Medicare and DMERC.

Special Payers – these are found on the PI web
site, along with forms and instructions.
Enrolling your Customer for
Real-Time Eligibility
Payers that DO require Eligibility Enrollment:

Complete Practice Insight 270/271
Registration Form for each customer.

For any Special Eligibility Payers, go to the
RT Eligibility web page to access Payer form.
Time to Play
Whose Enrollment is it
Anyway?
If your customer requests a payer and it is not on the
EDI payer list, what should you do?
Contact PI’s EDI Enrollment dept. Log an issue in Issue
Manager, call the Enrollment Dept, or send email to
enrollment@practiceinsight.net. Be sure to include the
electronic payer id (usually 5 digits) and any information
you have about the payer.
Whose Enrollment is it Anyway?
Give 2 or more reasons why an EDI enrollment
request might be rejected or delayed.
Missing signature. Illegible. Missing or Invalid
Provider Numbers, e.g, such as Provider ID #,
PTAN # NPI #, Tax ID #. Incorrect Provider
name. Individual provider information on form
instead of billing provider group information.
Whose Enrollment is it Anyway?
How will you know when your customer is
enrolled and can begin submitting claims?
Watch for an email, fax or letter from the payer.
You (the PI Reseller) may receive a CONF email from
Practice Insight. You or your customer can call the
payer to get verbal confirmation that the provider is
approved to submit claims via Practice Insight.
In Summary…

Take the time to PROFILE YOUR CUSTOMER
to get a complete and accurate assessment
of the customer’s EDI enrollment
requirements.

SETUP THE CUSTOMER IN EDI (add customer
record and provider records) BEFORE
SUBMITTING EDI Enrollment paperwork.
In Summary…

Support your provider -- they need your help!

Assist your customer in completing and
reviewing EDI enrollment forms.
(Rejected EDI enrollments create unnecessary
and painful delays!)

EDI enrollment can be part of your
implementation services and fees
In Summary…

Manage your customer’s expectations about
length of time to complete enrollments and
when they will be ready to “go live” with
EDI.

Track the EDI enrollments so that you are
aware of rejections and confirmations as
soon as possible.
In Summary…

Monitor the first batch of claims your new
provider sends to Practice Insight –react
quickly to claim rejections.

Making your customer’s first experience
positive with EDIinsight can be critical to your
success. Customers always remember
whether the start-up was smooth or rocky!
In Summary…

As with all EDIinsight issues, contact
Practice Insight when you need help.
To reach PI’s Enrollment Dept…



\
Log an issue in Issue Manager
Send email to enrollment@practiceinsight.net
Call 713.333.6000 (press Option #2)
st
1
BONUS
QUESTION!!!!
What is an ERA?
Electronic Remittance
Advice (electronic eob)
2nd BONUS
QUESTION!!!!
What is a EFT?
Electronic Funds Transfer
(monies deposited in
bank)
3rd BONUS
QUESTION!!!!
What is the difference between
an ERA and an EOB?
ERA is received via electronic file.
EOB is received on paper.