SolAce EMC Enrollment and Testing Process

Enrollment and testing are the hidden complexities of the electronic claims industry. You won’t find a clearinghouse that highlights these two items in their marketing materials, yet every single electronic claim submitter has to go through some or all of these steps in order to receive payment for electronic claims.

The process is a familiar one for other industries that use Electronic Data Interchange (EDI) in their day-to-day business operations. It is also a necessary business protocol in order to establish which companies you will trade data with and what the terms and conditions of that data exchange are. In the healthcare and insurance industry this process is very much controlled by the insurance companies, whereas in other industries the entities are more like peers with one another and are actually called trading partners for that reason.

This document should give you enough information to understand the overall steps and timeframes you can expect, and some tips to help you get through the process successfully.

Enrollment is the process of filing paperwork with insurance companies to be able to send electronic transactions to them (such as claims), and to receive electronic transactions back (such as remittance advices and reports). In general, you will need to enroll once for each of the following categories. This is the case with any electronic claims package, whether you are submitting directly to a payer or via a clearinghouse.

• One enrollment with a clearinghouse for all your commercial claims. This covers over 1,000 payers who just want to pay a clearinghouse and don’t care to bother with enrollment. However, there are a few payers in this large set that do require an additional step, such as a phone call or signed form to get a provider ID number.
• One enrollment for each Medicare region that you have offices in. If you have never submitted any Medicare claims before you need to use form CMS-855A, otherwise use the Trading Partner enrollment packet available from your regional Medicare office.
• One enrollment for each Medicaid state or contractor that you need to submit claims to.
• One enrollment for DMERC, Tricare, or Railroad Medicare claims.
• One enrollment for Blue Cross Blue Shield plans, unless your organization has been issued multiple organization-level PINs for BCBS.

Preparation

The Payer List area on this web site we diligently try to keep up to date with links to all the current enrollment forms. Try our web site first if you are looking for forms, print the forms out, read and fill them out, sign, and mail the packet in. Most insurance companies require the originals to setup your account, while some will accept a fax copy or email to get things started.

Contact Ivertex at (602) 439-2525 if you have any questions while filling out the forms. You will want to mark the ANSI 837 4010A1 options if you have multiple choices for what types of claims you will be sending. We are also frequently asked what the communications method should be. SolAce EMC supports these communications methods:

• Modem (also called asynchronous, BBS, or Zmodem)
• FTP (also called dial-up FTP)
• Secure FTP over the Internet (using either SSL or SSH)
• Automated scripting of a payer’s web portal
• If asked, our default EDI delimiters are: element = *, composite = : and segment = ~

SolAce EMC should provide all the settings necessary for you to communicate with a payer. While other products require you to research the payer's companion guides and input the settings, we prefer to build the settings in once for all our customers. If you find a payer whose settings are not already pre-configured within SolAce EMC, please, don't read that companion guide yourself, but ask us to decipher it for you and configure SolAce EMC so everyone can benefit from having one more direct connection available.

Completion

In return for your enrollment paperwork you will receive some instructions that includes, at a minimum, your Trading Partner ID or Submitter ID and a password to use with that ID. This information gets entered into SolAce on the Setup/Mailboxes screen to setup the electronic communications channel between you and the insurance company.

The time it takes to enroll depends on how long it takes you to fill out the paperwork, and how long it takes the payer to process it. Typical turn-around time is 3 days to 2 weeks.

Testing is the process of sending some transactions to the insurance company so they can make sure you have all the settings correct for their system. Testing is a critical step considering that anything but perfect transactions directly affects your payments and cash flow.

Data you send while in test mode is not processed for actual payment, but is reviewed by a human or automated system. The culminating event in the testing process is being granted production status. This means you can send live data and have it be processed by the insurance company as live data. When you are granted production status you will revisit the Setup/Mailboxes screen in SolAce EMC and change your mailbox from Test to Production mode. If you used real claims to test you would then resend your claims to submit them for payment.

Preparation

Each insurance company has a different approach to the testing process. A few companies offer blanket approval for submitters once their vendor has tested, but we still recommend testing to all our submitters because medical claims are complex data sets.

Most companies recommend sending 10 to 25 claims for a test. You can save some time by preparing a batch while you are waiting for your enrollment paperwork to be processed.

The steps you can expect to go through are described below.

• Pre-test / Self-test – Many insurance companies use a web portal or third party web site like EDIFECS™ (HIPAA Desk) to have you send a test transaction. This offloads their workload to an automated system that will give you feedback on whether the transactions look good or not. It will take you an hour or two to put together the data for this test, and the feedback from the web site is usually instantaneous. The pre-test usually goes very quickly.
• Live test – Almost all insurance companies require a submission of real claim data. A few companies want claims that were previously paid so they can compare the data, while most just want real data so it passes all the provider and patient ID edits in their processing system. You will typically get a response by the next business day, though we have seen some organizations take several weeks to respond. You can help expedite the process by checking your reports the same and next day, then calling the payer if you haven’t received anything electronically.
• Production Request – A growing handful of insurance companies use a self-testing model where you use a web site to pretest, then fill out a production request form when you think you are ready for production. The insurance company enables your account for production at this point, and you can send your transactions to their system as live data.

While testing and in production it is always important to review the reports you get back from the payer. When sending to a clearinghouse, the response for multiple payers may get combined into a single report, which is called consolidated reporting. Some detail may be lost in consolidated reporting, so SolAce will show you whatever comes into your inbox rather than trying to combine it all.

Completion

The THIN clearinghouse that we recommend for your commercial claims will setup your account so you can switch between test and production at will. Simply send a batch in test mode and if the reports look good go ahead and switch your mailbox to production mode in SolAce EMC. If you ever want to switch back to test mode for your THIN mailbox you can do so to see how a batch goes through without letting it go as live data. Other clearinghouses such as EDI Healthcare, CareVu, ASK, BCBS Arizona, and WebMD may have production request requirements so you have to let us know when you want to switch to production, and we then relay the request to the appropriate contact.

Most government and BCBS payers watch your testing closely and will notify you if there are problems and when you are cleared for production. When you are granted production status you will revisit the Setup/Mailboxes screen in SolAce EMC and change your mailbox from Test to Production mode.

The time it takes to make it through the testing process varies widely, from a single day for commercial claims, to 2-6 weeks for larger payers. There is no hard and fast rule. We have seen people test in as little as 3 days with large payers like EDS and Cigna, but this is rare and most people tend to take at least two weeks. Smaller payers have better turn-around in general. Payers who are not quick at responding can push the testing process timeframe out, so it is important to keep in contact with them.

At Ivertex we have staff devoted to assisting customers with testing. We can assist as little or as much as you want us to. Some options where our staff can be useful are described below.

• We can talk you through adding your Trading Partner settings and doing a test transmission over the phone.
• We provide forms and enrollment help as a courtesy: We cannot be responsible for any delays or errors on the payers’ part.
• Our Desktop Edition has a backup feature that allows us to exchange complete configurations between you and our support staff. This is useful so we can see the same setup you are looking at and verify everything is correct. It is also useful because we can do much of the configuration for you in our offices and then email you a backup file to restore on your PC.
• If you are using Enterprise Edition we can actually login to your installation (firewall restrictions allowing) and assist with the configuration and testing using your own system.
• We can assist by contacting the payer repeatedly to make sure they have your account setup properly and are analyzing test results in a timely manner.

Connections that we don’t yet have an automated transmit script we will assist by taking a claim file from you and work through the transmission testing from our office to make sure it is automated and working smoothly. SolAce can create a HIPAA compliant 837 for anyone that can be manually sent to the payer, but we want the transmission to be automatic for every one of our customers. We currently support over 120 direct connections and four clearinghouses, so adding a new transmit script is an easy task in most cases.

Checklist for Success

Reaching production status for payers that have a rigorous testing process requires one important attribute on everyone's part: persistence. Payers are deluged with requests from submitters and don't always have the staff to keep on top of things. Don't assume that leaving a phone message will result in a callback, keep nagging them until you get your answer. The support staff at Ivertex will do the same when we have tasks that need a response from the payer.

Do not stop submitting your paper claims just because it seems like your electronic claims are going through the test process fine. The payer may have another step that they didn't inform anybody of, or may experience a delay in approving you for production for no apparent reason. The last thing you want is to be surprised by a delay when you have been sitting on your claims for a month.