Corporate

EDI Glossary

A

American National Standards Institute (ANSI) Format:

Stream file format that uses transactions, segments, elements, identifiers, and delimiters. All data lengths are variable in this format. Specifications for the HIPAA-compliant ANSI X12N version 4010A1 implementation guides are available on the Washington Publishing Company Website. Per HIPAA implementation, this format is mandatory of the healthcare community.

Asynchronous Transmission:

In modem communication, a form of transmission in which data is sent intermittently, one character at a time, rather than a steady stream with characters separated by fixed time intervals.

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B

Beneficiary Eligibility:

A feature that enables providers to electronically access information regarding the eligibility data of beneficiaries.

Billing Service:

An entity that provides claims services to providers. It compiles medical information to build and transmit claims. They will collect claim information from a provider electronically or on paper and will bill the appropriate insurance payer. Note: You are responsible for verifying that claims are being transmitted electronically, and for the accuracy of claims that a billing service sends to CGS on your behalf.

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C

CGS Free Billing Software:

As a service to our providers, CGS offers a software package which allows billers to create an electronic claim file. For information, refer to the PC-ACE Pro32 Software Web page.

Claim Status Inquiry (CSI):

A feature that allows suppliers and providers to electronically check the status of claims. Find out if your claims have been paid, denied, or are still pending. EDI accepts the current ANSI X12 276/277 Claims Status Inquiry/Claims Status Response paired transaction sets.

Claim File:

Once claim data is entered into your Medicare billing software, the billing software then compiles the data and develops an electronic file in the National Standard or ANSI X12 format. This file is then transmitted electronically to CGS.

Clean Claim:

A claim that does not require investigation or development outside the Medicare operation on a prepayment basis.

Clearinghouse:

An entity that transfers or moves EDI transactions for a provider. A clearinghouse accepts multiple types of claims and sends them to various payers, including Medicare. Note: You are responsible for verifying that claims are being transmitted electronically, and for the accuracy of claims that a billing service or clearinghouse sends to CGS on your behalf.

Communications Software:

The software that enables one to send or receive information from one computer to another.

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E

EDI Customer Profile:

This form is used to provide CGS with your provider and vendor information as well as the type of request you are submitting. It is to be completed and submitted for all request for electronic transactions. This form is also used to communicate configuration changes. These changes range from contact name, address change, software vendor/billing service/clearinghouse change, data request changes or ceasing electronic billing.

Electronic Data Interchange (EDI):

The computer-to-computer electronic exchange of business documents using standard formats.

EDI Enrollment Form:

A CMS agreement stating that the provider is responsible for the Medicare claims sent by itself, its employees, or its agents. Each provider of health care services, physician, or supplier that intends to submit electronic media claims (EMC) must execute the agreement. The CMS EDI Enrollment Form must be completed prior to submitting EMC to Medicare. The signed form must be on file for each Medicare carrier that processes your claims before production claims may be transmitted.

Electronic Funds Transfer (EFT):

Automatically transferring payment to a provider's bank account.

Electronic Media Claims (EMC):

Transmitting claims by computer rather than submitting them on paper.

Electronic Receipt Listing (ERL):

A report that lists the number of claims received and accepted/rejected by CGS. This report will also show any errors that occurred which caused claims to reject and not get into the system.

Electronic Remittance Notice (ERN):

An electronic payment report, which lists claims that have been paid and/or denied. The ERN process may permit the provider to utilize automatic posting capability if they use a practice management system.

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F

Functional Acknowledgment Reports:

A report generated in the ANSI format to recognize received ANSI X12N files. This report is generated for each transaction received by CGS that contains enough data in a valid format to identify the user.

I

Internal Control Number (ICN):

A tracking number assigned by CGS to claims that were accepted into its claims processing system.

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M

Medicare Remit Easy Print (MREP):

Free software offered to providers. This software is used for viewing and printing theANSI ASC X12 835 HIPAA compliant Electronic Remittance Advice (ERA) and is available for installation via the Centers for Medicare and Medicaid Services (CMS) websiteExternal Website.

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P

Payment Floor:

The minimum amount of time a claim must be held before payment can be released. EMC claims must remain on the payment floor 13 days before payment is released. Paper claims must remain on the payment floor for 28 days before payment is released.

Proprietary Software:

This software is written or developed in-house for a company, and tailored to the specific needs of that company. Specifications for the HIPAA compliant ANSI X12N implementation guides are available on the Washington Publishing Company websiteExternal Website.

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R

Reader (Program):

A software program which is designed for the purpose of converting raw data to a recognizable format for interpretation.

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S

Stratus:

An asynchronous transmission mailbox system that allows users to dial directly into CGS's Gateway Service. This network is used to transmit claims and download reports.

Submitter ID:

An identification number assigned by the Part B Electronic Data Interchange department to identify electronic billers. Part B billers will be issued a separate Submitter ID by each Part B carrier to whom they transmit claims electronically.

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V

Vendor:

An entity that provides hardware, software, and/or ongoing technical support for providers.

Vendor Software:

Software written or developed by a third party entity (vendor) so that providers might submit claims to CGS. If you already use vendor software to manage your practice, contact the vendor to see if they offer a feature for submitting claims to Medicare.

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