1. What is EDI?
EDI stands for Electronic Data Interchange. It is the electronic exchange of data such as Claims, Electronic Remittance Advices and subscriber Eligibility transactions. In healthcare billing, Electronic Data Interchange (EDI) simplifies the process of sending information between the provider and insurance payer.
2. Why is EDI enrollment required?
This is the process of getting your practice linked to our clearinghouse for EDI transactions. Some payers require authorization for EDI transactions such as claims, ERAs, and eligibility. In other words, until your organization has completed all of the necessary registration processes, you will be unable to submit electronic claims to identified insurance payers.
3. What steps are involved in the EDI enrollment process?
During the enrollment process, our EDI team will complete clearinghouse registration, generate payer enrollments, and provide any required payer agreements or instructions to you that require your intervention.
4. What are some electronic services that require enrollment?
Claims, ERA (electronic remittance advice), Eligibility, and Patient Statements are some electronic services that require enrollment.
5. How can I determine which payers require enrollment?
During the enrollment process, our EDI team will review the payer list you provide while completing the Practice Enrollment Form. Our EDI team will inform you of the payers that require enrollment. Additionally, you can find which payers require enrollment on the payer list located on TriZetto’s website. You may also contact our EDI team by email at enrollments@practicesuite.com.
6. What type of information is needed for EDI enrollment?
To prepare for EDI enrollment, we will need the tax ID, NPI, provider numbers, and Medicare PTAN, if applicable. You would also need to be credentialed with the payers.
7. Where can I find my Provider Numbers or PTAN?
This information can sometimes be found on your credentialing paperwork. However, if you are unable to locate it, you can contact the payer directly to obtain this information.
8. What is credentialing? How do I know if I am credentialed by the payers?
Credentialing and Provider Enrollment refers to the process of requesting participation in a health insurance network as a participating provider. This process involves requesting enrollment/contracting with a plan, completing the plans credentialing/enrollment application, verifying education, training, and proven skills of healthcare practitioners. It is important to note that this is not the same as EDI Enrollment. PracticeSuite is not involved in the credentialing process. You can contact the payer directly to determine your participation and credentialing status with the payers.
9. If I am out of network with the payers, can I still complete EDI enrollment?
Some payers will require you to be credentialed and in-network before submitting EDI enrollments. Some will also reject the enrollments if you are not a participating network provider. Each payer is different. It is best to contact the payer if you are a nonparticipating provider to confirm their guidelines or wait until you have completed credentialing to submit enrollments.
10. Who is PracticeSuite’s clearinghouse partner?
TriZetto Provider Solutions, also known as Cognizant, is the preferred clearinghouse partner for PracticeSuite.
11. Who is Madaket Health?
Madaket is an enrollment partner of TriZetto Provider Solutions. Madaket Health has been contracted by our clearinghouse to facilitate the enrollment process for EDI (837 claims), ERA (835 remittance advice) and Eligibility (270/271 patient eligibility requests). Madaket Health provides the clearinghouse with the necessary documentation and work directly with Payers to help you successfully enroll for electronic transaction services.
12. What is the STEM Portal?
Strategic Enrollment Manager (STEM) is a portal within Madaket Health, an enrollment partner of TriZetto Provider Solutions. This portal allows us to initiate/generate the payer enrollments and access the required payer forms. PracticeSuite EDI team manages the STEM portal on behalf of our customers
13. I received the payer agreements/instructions from PracticeSuite EDI however, the clearinghouse does not show as Trizetto. Why is there a discrepancy on my forms between the clearinghouse that is listed?
Due to contractual agreements between clearinghouses and some payers, an intermediary is required (Ex: Payspan, CAQH, Change Healthcare, Office Ally, Echo Health, etc.) for processing. This will not affect receipt of ERA or claims submission via your clearinghouse.
14. Should I contact Trizetto or Madaket for assistance with EDI enrollments?
No. It is best for you to contact the PracticeSuite EDI team for questions regarding the enrollments. You can call 813-607-2800 or email enrollments@practicesuite.com.
15. Who should I contact for questions regarding the payer’s online portal enrollments?
Our EDI team can assist with some questions regarding the online portal enrollments. However, if you have questions regarding logging in, passwords, or technical issues it will be best to contact the payer directly because we have limited knowledge on how to troubleshoot the payer’s website.
16. Where do I return the payer agreements?
You may return the payer agreements to PracticeSuite EDI unless it specifically states to mail them to the payer or clearinghouse. In some instances, the payer may require original signatures, or the clearinghouse may need to sign. Only in those cases should the agreement be mailed to the payer or clearinghouse. You will receive detailed instructions from PracticeSuite EDI team regarding the agreements. Please be sure to pay close attention to those instructions.
17. How long does it take the payer to approve the EDI enrollment?
For payers that require enrollment authorization the turnaround times will vary. Each payer will have their own expected turnaround. Should you have questions regarding a payer’s processing time you may contact our EDI team.
18. How will I know the status of my enrollment request?
Some payers will notify the provider and clearinghouse of the enrollment status. You can track enrollment status in the clearinghouse. You will be given access and instructions on how to track your enrollments. In addition, our EDI Team will provide enrollment status updates during the enrollment process.
19. I received a notification from the payer regarding my enrollment. Should I send this to PracticeSuite?
Yes, please send all notifications from the payer to enrollments@practicesuite.com.
20. How soon am I able to start submitting claims?
You can submit claims to auto-approved commercial payers within 7-10 business days once your account is LIVE with our clearinghouse. For payers that require enrollment authorization the turnaround times may vary. Claims cannot be submitted for those payers until enrollment approval is received.
21. What are auto-approved payers/commercial payers?
These are payers that do not require enrollment authorization for claims submissions. For enrollments that are auto approved claims can be submitted once you are registered with the clearinghouse.
22. Can you assist with electronic funds transfer (EFT) set up?
Some payers will provide the EFT set up to the clearinghouse. If the payer provides the EFT set up instructions/forms to Trizetto, we will forward that to you. However, if the EFT info is not provided, the customer must contact the payer directly for EFT. Please note that if you are already set up for EFT you do not need to re-enroll unless your payment info has changed.
23. I do not want this payer enrollment; how can I cancel?
Contact enrollments@practicesuite.com or call 813-607-2800. Our EDI team will cancel the enrollment request.
24. How do I enroll additional payers or make changes to my enrollments?
You can contact PracticeSuite EDI Team at enrollments@practicesuite.com or call 813- 607-2800.
25. What is a Change of Vendor (COV)?
If a customer is currently submitting claims and receiving ERAs using our clearinghouse partner, TriZetto, a Change of Vendor can be submitted. This allows Trizetto to copy enrollment data from your current Trizetto site over to ours. Once the COV is completed by Trizetto you can submit claims and receive ERAs through PracticeSuite for those approved payers without requiring the lengthy enrollment process, in most cases