Unit 3: Electronic Solutions: EDI & Availity

1.3 Introduction

1.3 Highmark Electronic Transaction Requirements

1.3 Electronic Data Interchange (EDI)

1.3 About Trading Partners

1.3 Getting Started With Electronic Claim Submission

1.3 Availity Automated Inquiries and Transactions

1.3 Real-Time Capabilities

1.3 ASK Guidance (NY Only)

1.3 Disclaimers

1.3 Introduction

Highmark places a high priority on electronic exchange of information and electronic claims filing. This process is more efficient and cost-effective than conventional means – benefiting health care facilities, professionals, members, and insurers.

The company’s electronic commerce division, Electronic Data Interchange (EDI) Services, provides a host of services that make filing claims and accessing information faster and easier. These include:

• A claims clearinghouse where you can electronically submit claims and inquiries for Highmark
• Convenient technical support through a toll-free hotline
• Information on getting started in electronic claims filing

In addition, Highmark's provider portal, Availity, is available to all participating providers. Availity is an internet-based application for providers to streamline data exchanges between their offices and health insurance companies. Through Availity providers are able to submit claims through the HIPAA-compliant claim submission function. This provider portal also allows providers to verify enrollment, eligibility, benefits, claim status, and much more.

1.3 Highmark Electronic Transaction Requirements

In support of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, Highmark has taken steps to eliminate paper transactions with our contracted providers.

Due to their inherent speed and cost-effectiveness, electronic and online communications are integral in today’s business world and Highmark requires that all network providers participate in electronic programs sponsored or utilized by Highmark now or in the future.

All Highmark network participating providers are required to enroll in Availity^®, Electronic Funds Transfer (EFT), and paperless Explanation of Benefits (EOB) statements. All new assignment accounts must sign up for Availity and also enroll in EFT and paperless EOBs.

Availity is an easy online solution linking physician offices with Highmark and other health plans. Availity integrates all insurer-provider transactions into one system (e.g., eligibility and benefit inquiries, claim status inquiries, claim submission, authorization requests, etc.). This service is available at no cost to Highmark network participating providers.

Participating providers are also required to enroll to receive electronic funds transfers and paperless EOB statements.

• EFT is a secure process that directs Highmark claim payments to the provider’s checking or savings account as directed by your office. Payments are typically in the designated bank account by Wednesday of each week.
• Paperless EOB statements reduce the amount of paper flowing into the provider’s office. EOBs are available for viewing on Monday morning via Availity – which is two days earlier than receiving them by mail. For Pennsylvania, Delaware, and West Virginia providers, this information is also available for viewing within PNC’s Healthcare’s ECHO Health platform.

Important! Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) providers should use ASK for electronic claim submissions or Availity for administrative Transactions and EFT payments. Once an EFT payment is received, providers will be able to view EFT payments via Availity.

Additionally, Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) providers may still opt in to paper Explanation of Benefits.

Providers who are not currently registered to use Availity should go to the Register and Get Started with Availity Essentials webpage.

After becoming Availity-enabled, providers must also enroll in Electronic Funds Transfer (EFT) and paperless Explanation of Benefits (EOB) statements. Claims payments are generated from PNC-ECHO Health Trust. Electronic Remittance Advices (ERAs) are distributed using the ECHO Payer ID 58379. Providers may elect to receive EFT only or 835/EFT through the ECHO Health platform. To sign-up to receive EFT on the ECHO Health platform, visit their EFT/ERA enrollment page.

Virtual Credit Cards: Providers who have not registered to accept payments electronically will receive virtual credit card payments with their EOBs. Offices opted in to virtual credit cards (VCC) will receive notification for each payment via mail or fax, which will include a unique virtual credit card number and instructions for processing. Providers may opt out of VCC by visiting/calling ECHO Health at 800-890-4124.

Additional Payment Options: ECHO also offers payments via Medical Payment Exchange (delivers payments and EOBs electronically and gives providers the option to print a check at no cost, receive a virtual card payment, or enroll for EFT) or paper check. Explore more details about these options on ECHO Health’s platform.

Once providers are enrolled and start receiving EFT payments, they will no longer receive paper EOB statements or remittances. Providers will still be able to view the claims status and a copy of the EOB through Highmark’s provider portal, Availity. However, providers will need to visit ECHO Health’s platform to manage/change payment information.

After becoming Availity-enabled, providers must also enroll in electronic funds transfer (EFT) and paperless Explanation of Benefits (EOB) statements. To do this, please contact the Provider Service Center.

With Availity, an individual in your office or facility serves as the administrator. That individual can register with Availity online. The office administrator can begin the registration process on the Register and Get Started with Availity Essentials webpage. After registering an organization, the administrator can add other users from the administrator’s organization.

To learn more about registering and getting started with Availity, go to the Register and Get Started with Availity Essentials webpage.

If you need assistance with an existing account and cannot log in to submit a ticket, or have started the registration process and are experiencing issues, you can call 800-AVAILITY (282-4548). For more information about contacting Availity, click here.

1.3 Electronic Data Interchange (EDI)

Everyone has a stake in health care cost containment. Health care professionals, patients, insurance companies, and state and federal government are all affected by the high price of maintaining good health. Fortunately, technology can help simplify business operations and thus cut costs.

Due to their inherent speed and cost-effectiveness, electronic transactions and online communications are integral to today’s business world. Electronic transactions between health care professionals and insurers are essential to maintain efficiency. EDI makes electronic communications a viable method of streamlining claims processing and eliminating wasted time and money.

Highmark provides you the convenience and cost savings of electronic data interchange through various means. Some of the most common forms of provider electronic exchanges with Highmark include streamlined claims filing, acknowledgement information about your claims, inquiry features, and information retrieval.

In 1979, the American National Standards Institute (ANSI) chartered the Accredited Standards Committee (ASC) X12 to develop and maintain uniform standards for Electronic Data Interchange (EDI). ASC X12N is the section of ASC X12 for the health insurance industry’s administrative transactions.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Administrative Simplification provisions named ASC X12N as the mandated standard to be used for electronic transmission of health care transactions. In 2010, the Affordable Care Act (ACA) included additional provisions that addressed the use of transactions, building upon the requirements already in place through HIPAA.

Highmark EDI Services supports a variety of HIPAA-compliant electronic inquiry and claims transactions including, but not limited to:

To find out more about the EDI services available to Highmark Trading Partners in support of their electronic business activities, visit the Highmark EDI Services website. The site provides current information about transaction specifications, Trading Partner requirements, and enrollment applications.

Click on the applicable link to access the Highmark EDI Services website directly:

• Pennsylvania: https://edi.highmark.com/edi/index.shtml 
• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml 
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml 
• New York: https://www.ask-edi.com/

The link to the EDI Services website is also available on the Provider Resource Center – select Claims & Authorization, then Reimbursement Resources, and then Guidelines & Tips from the main menu at the top of the page.

1.3 About Trading Partners

A trading partner is an entity that conducts business electronically with Highmark. Providers, clearinghouses/billing services, and software vendors are the most common types of trading partners who enter into agreements with Highmark.

Before a provider, clearinghouse/billing service, or software vendor can begin to do business electronically with Highmark, an agreement must be executed. The agreement explains both Highmark's and the Trading Partner’s obligations as well as defines the terms, indemnification, and compliance with privacy standards. It further establishes the legal relationship and requirements within Highmark.

To view the Provider Trading Partner Agreement in its entirety, select the link titled Electronic Data Interchange (EDI) Services on the Provider Resource Center, or click on the applicable link below to access the site directly:

• Pennsylvania: https://edi.highmark.com/edi/index.shtml 
• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml 
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml 
• New York: https://www.ask-edi.com/ 

A provider is a health care professional, institution, or organization in whose name the bill is submitted and to whom payment should be made. A clearinghouse, or billing service, is an entity which submits claims or other transactions on behalf of professional or institutional providers.

• Providers doing their own electronic billing using a vendor software package must apply for their own Trading Partner number.
• Providers using a billing service or clearinghouse to conduct electronic billing must be affiliated with the Trading Partner number of the billing service or clearinghouse.
• Billing services and clearinghouses must obtain their own Trading Partner numbers for conducting electronic business with Highmark. In addition, customers (providers) must be affiliated to their Trading Partner number(s).

Complete an EDI Transaction Application to request a Trading Partner ID. The type of application depends on the business functions you will be performing. All applicants will be required to review and accept the terms of Highmark’s EDI Trading Partner Agreement. 

To complete an application, visit the Electronic Data Interchange (EDI) Services website via either the Provider Resource Center, or click on the applicable link below to access the site directly: 

• Pennsylvania: https://edi.highmark.com/edi/index.shtml 
• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml 
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml 
• New York: https://www.ask-edi.com/ 

Your Trading Partner Profile at Highmark includes many facts about your practice or facility, such as:

• Practice or facility name
• Address (both physical locations and where checks should be sent)
• National Provider Identifier (NPI)
• Individual Practitioners who submit claims under a practice’s Billing Provider Number
• NPI for each Practitioner

Highmark relies on Trading Partner and vendor contact information in case there are technical and/or business issues that require communication.

Changes to provider or trading partner information can affect how claims are received or processed by Highmark. We recommend that you remain diligent about reporting all changes within your practice as quickly as possible.

Electronic transaction exchanges with Highmark can be affected by certain changes made within your practice. In some cases, separate notification about your changes must be submitted to EDI Operations.

If a new provider is added to your staff who will receive payment directly from Highmark, you must add this provider to your Trading Partner number. If you do not complete this step, you will experience problems with receiving payment for this provider’s services.

If you need to report changes to Highmark, a specific request to change your Trading Partner information must be submitted. The forms can be found on the EDI website. You can access the website by selecting Electronic Data Interchange (EDI) Services by clicking the applicable link below: 

• Pennsylvania: https://edi.highmark.com/edi/index.shtml 
• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml 
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml 
• New York: https://www.ask-edi.com/

If after visiting the EDI website you still have questions about your Trading Partner Profile, please call EDI Operations at 800-992-0246.

1.3 Getting Started with Electronic Claim Submission

There are numerous things to consider when selecting an EDI vendor or clearinghouse. List your needs, determine your budget, and talk to others in your specialty using EDI. The following document is available to help you get started with electronic claim submission: EDI Frequently Asked Questions.

Practice Management System Vendor: Purchase a complete system from a reputable vendor. Complete system solutions typically include the hardware (personal computer, monitor, modem, and printer) and the software which includes electronic claims submission and possibly accounts receivable posting capabilities. Terms and conditions of each system vary from vendor to vendor.

Clearinghouse or Billing Service: Health care professionals can outsource their electronic claim submissions to private billing services and/or a clearinghouse. Terms and conditions vary from billing service to billing service and clearinghouse to clearinghouse.

The following suggestions should be considered when selecting a practice management vendor:

• Do they offer electronic claims submission of Highmark claims? Is the transmission direct or through an intermediary such as a clearinghouse? Is this capability offered with the basic electronic claims submission module at no additional charge?
• Can they support the submission of secondary claims and additional documentation electronically?
• Does the software capture and print the electronic reports provided by Highmark?
• Do they offer clearinghouse capabilities?
• How is installation performed?
• Ask about training on the software and if there is ongoing education provided. Is system help available (online or through paper manuals)?
• How much additional office software is included (word processing, email)?
• Do they offer internet access?
• Can you get a list of their clients in your specialty? What is the average turnaround time for a service call?
• What is the cost of the system?
• What features are standard with the system? 
  • Does the system support electronic eligibility and claim status inquiries and responses?
  • Does the system support electronic remittance advices?
  • Does the system support electronic acknowledgments?
• When there are changes in Highmark reporting requirements, how long will it take to update your software and how is it updated? What is the cost of normal updates, customization requests, and annual maintenance fees?
• Will the system automatically bill for co-insurance, copayment, or deductible after the primary insurance pays you?
• What other services do they offer (free conversion, loaner hardware)?
• Do they provide remittance advice information? Is there a fee for this package?
• What computer operating systems do they support?

Questions for a billing service:

• How frequently does the company submit your claims to the carriers involved?
• What kind of tracking reports does the service offer to its clients?
• Does the company provide credit and collection services?
• What is the cost per transaction?
• Are electronic eligibility and claim status inquiries supported?
• Are electronic remittances supported?
• Are electronic acknowledgments supported? 

If you will be submitting directly to any of the Highmark payers, enroll online by visiting the Electronic Data Interchange (EDI) Services website by clicking the applicable link below: 

• Pennsylvania: https://edi.highmark.com/edi/index.shtml 
• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml 
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml 
• New York: https://www.ask-edi.com/ 

Upon receiving your completed application, EDI Operations will process your request and verify that you have a valid National Provider Identifier (NPI). A Trading Partner ID will then be assigned to you.

Within 5 to 10 business days, you should receive a secure email listing your assigned Trading Partner number, login identification and password, and the transmission telephone number.

If you are billing through a Trading Partner, clearinghouse, or billing service, check with them regarding the registration process to affiliate your NPI to their Trading Partner number.

1.3 Availity Automated Inquiries and Transactions

Availity is an internet-based application for providers to streamline data exchanges between their offices and Highmark. This service is available at no cost to network participating providers.

Availity gives users real-time access to Highmark's membership, claims, and provider and payment systems, making your job easier. Availity seamlessly integrates all insurer-provider transactions into one system, such as inquiries on referrals/authorizations, eligibility, benefits, claims status, claims investigations, procedure/diagnosis codes, and provider/facility searches.

Availity can also be used for claims submissions, authorization requests, and provider information changes. Availity provides access to Highmark’s tools for real-time claim estimation and adjudication. Our Provider Resource Center is also accessible through Availity.

Availity is the preferred Highmark tool for inquiring about member information. Availity-enabled providers are expected to use this tool for all routine eligibility, benefit, and claim status inquiries. Practices must use Availity for routine inquiries that can easily be answered online. The expertise of the Provider Service staff will remain available for non-routine inquiries that require analysis and/or research.

If you need assistance with an existing account and cannot log in to submit a ticket, or have started the registration process and are experiencing issues, you can call 800-AVAILITY (282-4548). For more information about contacting Availity, click here.

1.3 Real-Time Capabilities

Highmark’s real-time tools are available to all Availity-enabled contracted providers and to providers who submit electronic claims through a practice management system.

These primary real-time capabilities include:

• Real-Time Provider Estimation allows providers to submit a claim (837) for a proposed service and receive a response (835) in real-time. The 835 response estimates the member liability based on the current point in time and the data submitted for the proposed service. This capability allows providers to identify potential member liability and set patient financial expectations prior to a service. This can also be used at the time of service to actually identify and discuss payment arrangements or collect member liability at the point of service.
• Real-Time Claims Adjudication allows providers to submit a claim (837) that is adjudicated in real-time and receive a response (835) at the point of service. This capability allows providers to accurately identify and discuss payment arrangements or collect member liability based on the finalized claim adjudication results.

Other supporting capabilities related to real-time claim adjudication include:

• Accelerated Payment
• Accelerated Member Explanation of Benefits (EOB) on the Highmark Member portal

These real-time capabilities give providers the ability to discuss member financial liability with patients when services are scheduled or provided. Providers could also collect applicable payment or make payment arrangements at the time of services, if they wish to do so.

Providers who are interested in integrating real-time capabilities within their practice management system should discuss this functionality with their software vendors. They should also review the Electronic Data Interchange (EDI) transaction and connectivity specifications in the Resources section on the EDI website.

• Pennsylvania: https://edi.highmark.com/edi/index.shtml 
• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml 
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml
• New York: https://www.ask-edi.com/ 

Ask Guidance (NY Only)

To obtain information on or sign up for Electronic Claims Submission with ASK, please visit their website: https://www.ask-edi.com. Click on "Getting Started" on the menu bar.

Fill out the online form completely to register and click 'Submit'. If you would like to contact ASK by phone, call their toll free number at 800-472-6481; press option 1 for New York Customers and select option 1 again to connect to an EDI Helpdesk specialist.

Click the 'Resource Center' tab for:

• Payer News
• General Information
• CAQH-CORE Operating Rules
• ANSI Testing Guidelines for Batch Transactions

ASK accepts and edits electronic claims submissions using the following formats:

• ANSI X12 837P 5010 based on the HIPAA Implementation Guides (Professional)
• ANSI X12 8371 5010 based on the HIPAA Implementation Guides (Institutional)

Providers receive a clearinghouse response report for each electronic submission that indicates:

• Whether we have received the file
• The number of claims submitted successfully
• The data fields that need to be corrected before electronically resubmitting a claim returned for edit errors

When you enroll with ASK, you will be offered a one-year free trial membership to ASK's commercial clearinghouse, EDI Midwest. This offer provides you with the option of clearing other payers' claims through ASK. EDI Midwest routes claims to 800 payers around the nation.

EDI Midwest will only accept claims that can be sent to their final destination electronically. Your ASK EDI Account Representative can give you more detailed information about EDI Midwest at the time you enroll to submit your claims to ASK. You can contact ASK directly at 800-472-6481.

If you elect not to use the services of EDI Midwest, please make arrangements with your current clearinghouse vendor or submitter to have non-Blue Cross Blue Shield claims submitted directly to the appropriate payer.

We will continue to process claims destined for our vendors and all of our lines of business including: Non Direct-Bill ITS/BlueCard, Express Scripts, and Federal Employee Program (FEP).

We require the submission of the provider's Billing NPI number and not the 12- digit provider number on the claim form. Mail all claims, (Local, Indemnity, and Managed Care, including Senior Blue HMO and BlueSaver plans), to:

1.3 Disclaimers

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.