1. What is EDI?

2. Where can I get the EDI specifications for my MassHealth electronic claims?

3. How do I know that my claims file was received and accepted by MassHealth?

4. What is a 997?

5. I didn't receive a 997, what do I do?

6. How do I interpret the 997 transaction information?

7. What documents should I have available for successful healthcare transaction processing?

8. What do the different electronic transaction numbers mean?

9. What is the Transaction Implementation Guide and where can I get one?

10. What is a companion guide and how can I get one?

11. What is a MassHealth Trading Partner Agreement and do I need one?

12. How do I arrange to receive the 835 transaction?

13. What documents should I have available for successful 835 transaction processing?


1. What is EDI?

EDI stands for Electronic Data Interchange which facilitates the exchange of electronic files. The term EDI is the industry standard terminology for electronic transactions.

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2. Where can I get the EDI specifications for my MassHealth electronic claims?

The EDI specifications for MassHealth electronic claims are based on the following documents:

  • Transaction Implementation Guide
  • Companion Guide
  • Billing Instructions
  • Provider bulletins
  • Message texts

Transaction Implementation Guides can be found on the Internet at:

MassHealth-specific documents can be found on the Internet at www.mass.gov/MassHealth.

 

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3. How do I know that my claims file was received and accepted by MassHealth?

MassHealth will generate a 997 acknowledgement. The 997 will contain data indicating the number of segments received in your file, and their status. A status of "A" indicates that the segment was accepted, a status of "R" indicates that the segment was rejected. Only the segments that are rejected need to be corrected and resubmitted.

Verifying that a 997 is received for each submitted file is the responsibility of the submitter. The 997 should be downloaded from the NewMMIS Provider Online Service Center or via the healthcare transaction service (HTS) formerly known as system-to-system.

The 997 should be available for download no later than one business day of receipt of your file. If you cannot download a 997 within that time frame, you should contact the MassHealth Customer Service at 1-800-841-2900 for assistance.

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4. What is a 997?

The 997 is a HIPAA-defined transaction that indicates acknowledgement of receipt and status of each segment in an EDI transaction.

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5. I didn't receive a 997, what do I do?

If you haven't received a 997 by the within 24 hours after submission of your 837 file, you must contact MassHealth Customer Service to identify the cause of the problem. Possible issues include an incorrect file name, invalid format, or the file was not received by MassHealth. Contact MassHealth Customer Service to identify the issue and ensure a timely and accurate resolution.

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6. How do I interpret the 997 transaction information?

MassHealth has created a helpful billing tips flier to explain how to read your 997. This flier, Reading the 997 Acknowledgment from MassHealth, pdf format of    flyer_reading-997-acknowledgement-837-file-submiss  can be accessed in the Billing Tips section on www.mass.gov/Masshealth.

For more information, you can review the 997 Transaction Implementation Guide, the HIPAA regulations and implementation guides can be found on the Internet through the following links.

 

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7. What documents should I have available for successful healthcare transaction processing?

While most software systems have already incorporated the HIPAA transaction processing rules, the following are important source documents essential in creating HIPAA transactions. You should have a copy of the Companion Guides that are specific to your transaction type, ie; 270/271, 276/277, 820, 834 Inbound, 834 Outbound, 837I, and 837P.

  • Companion Guides
  • HIPAA Implementation Guide
  • The MassHealth provider manual specific to your provider type
  • All MassHealth bulletins that have been issued for your provider type.

Provider manuals and publications are located in the Provider Library, accessible from the MassHealth Regulations and Other Publications link on www.mass.gov/masshealth.


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8. What do the different electronic transaction numbers mean?

The transaction numbers are:

  • 270/271: Eligibility and response - eligibility in a health plan
  • 277/276: Claims status inquiry and response - health care claim status
  • 278: Prior authorization - referral certification and authorization
  • 820: Premium payment - health plan premium payments
  • 834: Enrollment - Inbound enrollment and disenrollment in a health plan
  • 834: Enrollment - Outbound enrollment and disenrollment in a health plan
  • 835: Remittance advice - healthcare payment and remittance advice
  • 837: Claims - health care claims and equivalent encounter information
  • NCPDP 5.1: Retail pharmacy claims - retail pharmacy claims and equivalent encounter information

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9. What is the Transaction Implementation Guide and where can I get one?

Each transaction has an Implementation Guide that specifies the official government set of general rules surrounding the transaction. All covered entities must abide by these constraints. HIPAA regulations and implementation guides can be found on the Internet at:

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10. What is a companion guide and how can I get one?

A companion guide is used in conjunction with the HIPAA Implementation Guide. It details how a specific payer interprets the data elements, and the information they require for processing claims.

For MassHealth Companion Guides, go to the MassHealth Provider Library located under the MassHealth Regulations and Other Publications link.



 

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11. What is a MassHealth Trading Partner Agreement and do I need one?

A Trading Partner Agreement (TPA) is "an agreement between the covered entities (HIPAA Regs: 45 CFR Part 162.915) that are engaged in EDI transactions. TPAs specify the rules and responsibilities of each party involved in the transaction in addition to indicating requirements such as communications, financial arrangements (which entity is responsible for telecom costs).

All MassHealth participating providers are required to complete and submit a TPA even if they do not plan to submit claims electronically. You can get the MassHealth Trading Partner Agreement pdf format of    hipaa-trading-partner.pdf  from the Provider Forms link under the MassHealth Regulations and Other Publications section.

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12. How do I arrange to receive the 835 transaction?

Contact MassHealth MassHealth Customer Service to coordinate the necessary setup for receipt of the 835 transaction. Depending on whether you are a provider using a clearinghouse or billing agent, a provider submitting your own claims, or an organization managing multiple providers, there are unique sets of information that are required to complete the registration process.

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13. What documents should I have available for successful 835 transaction processing?

The management of your 835 transaction processing will be specific to your organization. The information technology staff may process the 835 file and use it for posting, or you may be responsible for interpreting claim results.

The following are the reference tools available to successfully manage your 835 transaction processing. Depending on how your organization manages the 835 processing, you may need to have a copy of the following documents that are specific to your transaction type:

  • 835 Implementation Guide
  • 835 MassHealth Companion Guide
  • 837 Implementation Guide
  • 837 MassHealth Companion Guide
  • The MassHealth provider manual specific to your provider type
  • All MassHealth bulletins that have been issued for your provider type.

Download a copy of the MassHealth Companion Guide.
The 835 and 837 Implementation Guides can be downloaded from http://www.wpc-edi.com.

 

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This information is provided by MassHealth.