Claims Gateway

EDI Direct accepts electronic transactions for an extensive list of payers.

EDI COMMERCIAL SUPPORT
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Our services include:

  • Transaction clearing, specializing in X12N
  • Reporting services
  • Online remittance advice
  • Technical support
  • Web data exchange
  • Claim management tools

Transactions may be submitted to EDI Direct 24 hours a day, 7 days a week. Visit the Claims Payer List for information regarding available transactions, specific plans support, enrollment information, payer companion guides, and much more.

Announcements

EDI Services to Common Ground Healthcare Discontinued

As of 12 midnight EST on December 31, 2016 Xerox EDI will no longer be accepting claims for the Common Ground HealthCare (77170) payer.

Updated Payer Discontinuation Notice: BrickStreet Mutual Insurance Shutdown Delayed

EDI Direct will no longer accept 837 claim files for BrickStreet Mutual Insurance after September 11, 2014. This has been extended from the original shutdown date of August 9, 2014. BrickStreet is not currently ready to transition to their new vendor. As a reminder, we no longer accept new enrollments for BrickStreet submitters.

Payer Discontinuation Notice: Allstate, Deerbrook and Encompass

Effective November 19, 2013 at 10:00 PM EST, EDI Direct will no longer accept 837 claim files or deliver 835 remittance advice for the following payers:

  • Allstate Insurance (Payer ID 77066)
  • Deerbrook Insurance (Payer ID 77069)
  • Encompass Insurance (Payer ID 77068)

To enroll with the new vendor, sign up online with Jopari or call E-Bill Registration at 1-866-269-0554. Allstate, Deerbrook and Encompass will generate paper remittance advice for any claims received during the vendor transition period.

New Payers Coming Soon for Electronic Claims Submission

Effective January 1, 2014, the EDI Direct Claims Gateway will begin accepting 5010 X12N 837 Professional and Institutional Healthcare Claim Transactions for the following payers:

  • Common Ground Healthcare Cooperative (Payer ID 77170)
  • HealthyCT (Payer ID 77180)

Please check back in November for trading partner enrollment instructions and payer specific companion guides.

Gold Coast Health Plan (Payer ID 77160) to Offer Electronic Explanation of Benefits Retrieval

Effective Monday, November 5, 2012, version 5010 X12 835 transactions will be available for GCHP. In addition to accepting version 5010 X12N 837 Professional and Institutional Healthcare claim transactions on behalf of GCHP, EDI Direct will enable the retrieval of electronic EOBs from GCHP.

Vendors requesting to retrieve the 835 transaction must have authorization from their provider customer. Please visit our Claims Payer List and select Gold Coast Health Plan for more information on trading partner enrollment and 835 provider authorization.

*Please note that the 835 transaction is not available for WINASAP5010 users.

Payer Discontinuation Notice

Effective July 31, 2012,  EDI Direct will no longer accept claims for Peach State Health Plan (Payer ID 77084).  Please refer to the Peach State website, or contact the Peach State Health Plan EDI Support Unit at 1-800-225-2573 ext. 25525, to inquire about electronic claim submission methods.

EDI Direct will continue to support the 4010 format for existing Peach State Health Plan trading partners through the July 31, 2012 termination date.  We look forward to continuing our trading partner relationship with you on existing or new accounts. Please visit our Claims Payer List to view our currently offered payers.

5010 Readiness

This page is updated periodically to provide you with information on the implementation of 5010 HIPAA transaction standards and 5010 support.

Overview

On January 16, 2009, Health and Human Services (HHS) published two final rules to adopt updated HIPAA standards; these rules are available at the Federal Register. For more detailed information, go to the HHS website.

HIPAA Compliance Dates 

  • January – December 2011 – Partner testing and implementation of the new ASCX12 5010 transaction version.
  • Until December 31, 2011 – The final rule allows dual use of either the previous version 4010A1, or the new version 5010.
  • January 1, 2012 – Compliance date for 5010. Use of the previous ASCX12 version 4010A1 must be discontinued. Only the updated 5010 ASCX12 version standard may be used.
  • June 30, 2012 – 180-day discretionary enforcement period for 5010 ends

Payer Readiness

The following Payers are 5010 production-ready:

  • Gold Coast Health Plan – Payer ID 77160
  • Effective Wednesday, February 8, 2012, Gold Coast Health Plan began accepting 5010 X12N while continuing to accept 4010 X12N production transactions. GCHP will continue to accept 4010 X12N transactions until June 30, 2012.
  • Allstate Insurance – Payer ID 77066
  • Encompass Insurance – Payer ID 77068
  • Deerbrook Insurance – Payer ID 77069
  • Effective Friday April 13, 2012 at 6:00pm ET, Allstate, Encompass and Deerbrook will discontinue 4010 X12N and begin accepting X12N 5010 production transactions. All X12N 4010 transactions will be rejected after this transition time.
  • Allstate Workplace Division – Payer ID 77083
  • Effective Friday May 1, 2012 at 12:00am ET, Allstate Workplace Division will discontinue 4010 X12N and begin accepting 5010 X12N production transactions.  All 4010 X12N transactions will be rejected after this transition time.
  • XL Health/Care Improvement Plus – Payer ID 77082
  • Effective Monday May 7, 2012 at 12:00am ET, XL Health/Care Improvement Plus will begin accepting 5010 X12N and continue to accept 4010 X12N production transactions.
  • Brickstreet Mutual Insurance – Payer ID 77025
  • Effective Monday June 25, 2012 at 12:00am ET, Brickstreet Mutual Insurance will discontinue 4010 X12N and begin accepting 5010 X12N production transactions. All 4010 X12N transactions will be rejected after this transition time.

Trading Partners may begin submitting 5010 test files for the following payers:

  • Peach State Health Plan – Payer ID 77084
  • BrickStreet Mutual Insurance Company – Payer ID 77025
  • XL Health/Care Improvement Plus – Payer ID 77082
  • Allstate Workplace Division – Payer ID 77083
  • Allstate Insurance – Payer ID 77066
  • Encompass Insurance – Payer ID 77068
  • Deerbrook Insurance – Payer ID 77069

EDI Direct will keep you updated as more Payers become ready to begin testing 5010.

EDI Direct will be using validation guidelines to validate for:

  • SNIP type 1 – EDI syntax integrity testing
  • SNIP type 2 – HIPAA syntactical requirement testing
  • SNIP type 3 – Balancing
  • SNIP type 4 – Situational Testing

Providers that do not have the ability to submit 5010 transactions may submit to EDI Direct using WINASAP5010 for the following payers ONLY:

  • Gold Coast Health Plan
  • Peach State Health Plan
  • BrickStreet Mutual Insurance Company

Did you know?

You can visit http://www.wpc-edi.com to obtain 5010 companion guides and acknowledgment implementation guides in X12 version 5010.You can also find reference tools that will show you the change description for the 4010 to 5010 versions.

Provider Notice

Looking to send claims electronically for one or more of our offered payers? Check out our Approved VBC List to see if the vendor, billing agent, or clearinghouse you currently use for claims submission is available for the payer(s) of interest to you. If your vendor, billing agent, or clearinghouse is listed, but not available for the payers of interest, or not included in the list at all, please take the follow steps:

  • Call your vendor, billing agent or clearinghouse helpdesk and explain that you wish to submit claims electronically to EDI Gateway for the payer(s) of interest on our claims payer list. You should receive a ticket request number. Please record this for future use.
  • Complete our Provider Survey. The survey provides us with the information we need to work with your vendor to establish an EDI connection to us. Please include the ticket request number issued by your vendor, billing agent, or clearinghouse as this helps in facilitating the process and tracking progress.

Please Note: If your vendor, billing agent or clearinghouse is included on our Approved VBC List for the payers you wish to send claims to electronically, you DO NOT need to complete the survey. Simply contact your billing agent’s or clearinghouse’s helpdesk and inquire as to how you can add the payer for electronic claim submission to EDI Direct.

Have questions regarding coverage, procedures, billing codes, or the type of claim you should use? Already submitted a medical bill or claim successfully and need to obtain a status or find out why it has been denied? These types of inquiries should be directed to the appropriate insurance payer.

Find provider services and contact information for our available payers ›