Electronic Claims Submission

1. Purpose
   The purpose of this policy is to establish requirements and guidelines for the electronic submission of healthcare claims to ensure timely processing, accurate adjudication, regulatory compliance, and administrative efficiency.
   
   For more information, go to Claim Support Information for Providers


2. Scope
   This policy applies to:
   
   • Participating and non-participating providers
   • Hospitals and healthcare facilities
   • Billing services and clearinghouses
   • Any entity submitting claims electronically on behalf of a provider
   
   This policy applies to both professional and institutional claims.


3. Policy Statement
   Electronic claim submission is the preferred and recommended method for submitting healthcare claims. Providers are encouraged to submit claims electronically whenever possible to improve processing accuracy, reduce administrative costs, and accelerate claim adjudication.
   
   Claims submitted electronically must comply with all applicable federal and state regulations, industry standards, and payer-specific requirements.


4. Benefits of Electronic Claims Submission
   Electronic claims submission provides the following benefits:
   
   • Faster claim receipt and processing
   • Reduced mailing and administrative costs
   • Improved claim accuracy through electronic validation
   • Reduced risk of lost or delayed claims
   • Faster identification and correction of claim errors
   • Electronic acknowledgment of claim receipt
   • Improved tracking and reporting capabilities
   • Reduced paper consumption and storage requirements


5. HIPAA Compliance Requirements
   All electronic claims must comply with the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification requirements, including:
   
   5.1 Standard Transactions
   Claims must be submitted using approved HIPAA transaction standards, including:

• 837 Professional (837P)
• 837 Institutional (837I)
• 837 Dental (837D), when applicable

5.2 Standard Code Sets
Claims must utilize current and valid:

• ICD diagnosis codes
• CPT procedure codes
• HCPCS procedure codes
• CDT dental codes, when applicable
• Revenue codes, where required

5.3 Unique Identifiers
Claims must contain valid identifiers, including:

• National Provider Identifier (NPI)
• Tax Identification Number (TIN), as applicable
• Member identification number
• Other required payer-specific identifiers

5.4 Privacy and Security
Organizations submitting claims electronically must:

• Protect Protected Health Information (PHI)
• Utilize secure transmission methods
• Restrict access to authorized personnel
• Maintain appropriate audit and security controls
• Comply with applicable privacy and security regulations

6. Claim Submission Requirements

6.1 General Requirements
Electronic claims must:

• Be submitted through an approved clearinghouse or direct connection
• Contain complete and accurate information
• Include all required claim data elements
• Meet applicable formatting requirements
• Pass front-end validation edits

Claims that fail required edits may be rejected and returned for correction.

6.2 Professional Claims
Professional claims must include:

• Rendering provider information
• Member information
• Dates of service
• Diagnosis codes
• Procedure codes
• Charge amounts
• Place of service
• Required modifiers, when applicable

6.3 Institutional Claims
Institutional claims must include:

• Facility information
• Admission and discharge information
• Revenue codes
• Diagnosis and procedure codes
• Occurrence codes, when applicable
• Required UB-04 data elements

Where applicable, the Medical Record Number field must be populated in accordance with payer requirements.

7. Coordination of Benefits (COB)
   Secondary claims may be submitted electronically when:
   
   • The primary payer has processed the claim
   • Primary payer payment information is included
   • Coordination of Benefits data is transmitted in accordance with the applicable 837 transaction standard
   
   Providers must retain supporting documentation related to primary payer adjudication.


8. Claim Acknowledgment and Rejections
   Submitters should monitor all electronic acknowledgment transactions and reports.
   
   Rejected claims must be:
   
   1. Reviewed promptly.
   2. Corrected as necessary.
   3. Resubmitted within applicable filing time limits.
   
   Receipt of an acknowledgment does not guarantee payment or final acceptance of a claim.


9. Timely Filing
   All electronic claims are subject to applicable contractual, regulatory, and policy-based filing limits.
   
   Submitting a claim electronically does not extend filing deadlines.
   
   Providers are responsible for ensuring claims are successfully accepted before filing deadlines expire.


10. Paper and Fax Claims
    Electronic submission is preferred.
    
    Paper claims may be accepted only when:
    
    • Electronic submission is unavailable;
    • Required by law or regulation; or
    • Specifically authorized by the payer.
    
    Faxed claims are not accepted.


11. Record Retention
    Providers must maintain claim records and supporting documentation in accordance with:
    
    • Federal regulations
    • State regulations
    • Contractual obligations
    • Organizational record retention policies
    
    Documentation must be available upon request for audit, review, or investigation purposes.


12. Provider Support
    Providers requiring assistance with electronic claim submission should contact the appropriate:
    
    • Provider Services department
    • Electronic Data Interchange (EDI) support team
    • Designated Account Manager
    • Approved clearinghouse support organization


13. Non-Compliance
    Failure to comply with this policy may result in:
    
    • Claim rejection
    • Processing delays
    • Requests for additional information
    • Denial of claims
    • Compliance review or corrective action


14. Related Documents
    
    • HIPAA Administrative Simplification Standards
    • EDI Trading Partner Agreement
    • 837 Professional Companion Guide
    • 837 Institutional Companion Guide
    • Provider Manual
    • Coordination of Benefits Guidelines