Electronic Billing & EDI Transactions

This section contains information on:

• Our Electronic Data Interchange (EDI) transaction and corresponding paper claims requirements;
• Links to those Chapters of the Medicare Claims Processing Manual (pub.100-04) that contain further information on these types of transactions;
• Our Health Insurance Portability and Accountability Act (HIPAA) contingency plans;
• The Administrative Simplification Compliance Act (ASCA) requirement that claims be sent to Medicare electronically as a condition for payment;
•  How you can obtain access to Medicare systems to submit or receive claim or beneficiary eligibility data electronically; and
• EDI support furnished by Medicare contractors.

The information in this section is intended for the use of health care providers, clearinghouses and billing services that submit transactions to or receive transactions from Medicare fee-for-service contractors. EDI is the automated transfer of data in a specific format following specific data content rules between a health care provider and Medicare, or between Medicare and another health care plan. In some cases, that transfer may take place with the assistance of a clearinghouse or billing service that represents a provider of health care or another payer. EDI transactions are transferred via computer either to or from Medicare. Through use of EDI, both Medicare and health care providers can process transactions faster and at a lower cost.

Please see pages on specific types of EDI conducted by Medicare for related links and downloads as applicable.