Electronic Health Care Claims

How to Submit Claims: Claims may be electronically submitted to a Medicare Administrative Contractor (MAC) from a provider using a computer with software that meets electronic filing requirements as established by the HIPAA claim standard and by meeting CMS requirements contained in the provider enrollment & certification category area of this web site and the EDI Enrollment page in this section of the web site. Providers that bill institutional claims are also permitted to submit claims electronically via direct data entry (DDE) screens.

How Electronic Claims Submission Works: The claim is electronically transmitted from the provider's computer to the MAC. The MACs initial edits are to determine if the claims meet the basic requirements of the HIPAA standard. If errors are detected at this level, the entire batch of claims would be rejected for correction and resubmission. Claims that pass these initial edits, commonly known as front-end edits, are then edited against implementation guide requirements in those HIPAA claim standards. If errors are detected at this level, only the individual claims that included those errors would be rejected for correction and resubmission. Once the first two levels of edits are passed, each claim is edited for compliance with Medicare coverage and payment policy requirements. Edits at this level could result in rejection of individual claims for correction, or denial of individual claims. In each case, the submitter is sent a response that indicates the error to be corrected or the reason for the denial. After successful transmission, an acknowledgment report is generated and is either transmitted back to the submitter of each claim or placed in an electronic mailbox for downloading by that submitter.

HIPAA TR3s can be purchased at the official Washington Publishing Company (WPC) website.

For more information please contact your local MAC or refer to the Medicare Claims Processing Manual (IOM Pub.100-04), Chapter 24.