EDI

Electronic data interchange, or EDI, is a regular part of the vocabulary for every home care agency that services clients who receive Medicaid or VA services. EDI is how you send your billing information in a HIPAA compliant manner to a billing clearinghouse for claim management. CareSmartz supports both 837P(professional) and 837I (institutional) claim files for many different clearinghouses and MCOs.

Step 1:

Admin Settings>Agency>Billing Information

 First, select your Clearinghouse from the options at the top of the page. 

Then, indicate whether you file as a person or as a company 

Fill in the data in text boxes.Everything with an * is required.You must also select your Tax type and include the last 4 digits of your ZIP code.You can find the last 4 digits at USPS.com if you don’t know them.

In the next section of the page, you will need to add the Sender ID and Receiver ID that you receive from the clearinghouse or MCO.

In case of Availity, the Sender ID: 5010 and Receiver ID: 030240928
The Sender Code is unique for each Agency, however if the Agency does not have it 5010 will work. 

The only required information in the Submitter Details is your phone type and phone number (no spaces or special characters).

If your clearinghouse requires you to set up an SFTP account, you will add the details in the last section of the page.This will be a required step for uploading the EVV reports to HHAeExchange.Other clearinghouses may ask for this as well.

Step 2: Payer Profile set up

Hover over the Client module and click on Payers. 

 In the Payer Details screen, select Company.

Add the name of the insurance company in the text field

 When you select from the drop-down, the Payer ID will auto-fill.

If your company isn’t present in the drop-down, you can add it manually and then add the Payer ID manually.

The only other required information at the top of the page is the Type of payer. In order to create EDI files, you will need to select Medicaid or Insurance.

Many payers require that the payer address be included in the EDI file, so please make sure to enter that data.

Once you save the payer, the next step is in the Payer profile, on the billing tab.  Scroll to near the bottom of the page where you will see “ICD10 HCPCS and Revenue Codes.Click on +Procedure Codes.

Select the Service Type from the drop down

and then enter the individual codes for the time increments required by this particular payer.

You will need to add the numbers for all of the service types that you provide. 

Step 3:

For full details on how to set up a new client, please see the video:Client add and edit.The important elements for EDI are on the main page, in the assessment and on the rates page.

On the main page of the client profile, you need to select the “place of service” where the care will be provided. Home is selected by default; you only need to change it if the care is generally provided elsewhere.

You should add the Medicaid ID number here:

Now you need to make sure that the profile includes the ICD-10 diagnosis codes related to this client.

Click on the Claim Codes Tab.

Add the codes that are appropriate for the client.  Be sure to check the box to indicate which code is the primary one for the majority of the service you provide.

Next, you need to configure the payer profile, so the correct insurance provider will get the bill.

Go to the rates tab and select +Existing Payer.

Enter the name of the insurance in the text field and click Search. 

Use the Select icon to select the correct payer.

This will open the Add Client Payer window.Select “Primary” in the Rank field.

Add the Member ID number in the text field.

Then, select the Payment Distribution.For Medicaid EDI files, select Client Authorization.

Add the client-specific details for the authorization and click save.

You can add multiple authorizations for the same insurance if there is more than one.

Some Payers require the Claim File Indicator Code, so it's best to set it up from the start.

You can now also add the Group Name, Group Number, and Insurance Type Code.

If the client is the subscriber to the insurance plan, make sure that the box is checked to indicate that. If the client is NOT the subscriber, you will need to uncheck the box and then add the contact details for the person who is.

Once you have all the authorizations added, click the save button for the client payer.

Now, you’re ready to create schedules that you can turn into EDI files to submit to your MCO or your clearinghouse.

If you have set up the assessment with the ICD codes, all the necessary data will be in the schedules you create. From the basic schedule window, you can also adjust the fields if, for instance the place of service for a particular schedule will NOT be the regular place of service or if the primary diagnosis code for this visit is different from the pre-set primary code.

PLEASE NOTE:Once schedules have been created, the place of service and ICD codes will not change, even if you update the plan of care.If the information in the care plan changes, you will need to update the schedules manually.Any NEW schedules created will have the new data.

To manually change the claim-related information which is associated with the schedule, navigate in the schedule window to the Claim info section. Here, you can make appropriate adjustments, and you will be able to save to the whole recurrence pattern if you need to.

The final step to submit your claims is to create your invoices like you usually do.On the Finalized Invoice batch screen, you’ll see a “Generate EDI” icon.Just click the button, and the EDI file will generate.For many clearinghouses and MCOs, you will need to save the file and then go into the website for the clearinghouse and upload the file.

IMPORTANT: If there is any missing information that is required to generate the claim file, the CareSmartz360 system will generate a conflict and show exactly which information is missing.Every schedule has a unique schedule ID in the CareSmartz360 system. If there is any value missing from a schedule, an information pop-up page will appear, detailing which schedule is missing which piece of data. You will be able to locate the schedule ID from the Finalized Invoice batch screen, make the corrections, and then download the EDI file for submission.

Check List:

Admin Settings>Agency>Billing

Payer Profile>Payer ID

Payer Profile>Procedure Codes

Client Profile>Main Tab>Place of Service

Client Profile>Assessment>ICD codes

Client profile>Payer Configuration

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