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HH01: History of Home Health - 3.0 Lecture Hours

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HH04: Medicare Billing Overview – Unpacking the EDI Packet  & Clearinghouses Copy

Ian V. Chestnut July 26, 2021

Different ways to submit claims
Unpacking the EDI Packet  & Clearinghouses


EDI Packet

  • EDI Application
  • EDI Enrollment Agreement
  • Provider Authorization Form
  • Software Download Information
    • PC-ACE Pro32 Software
    • PCPrint for Part A Electronic Remittances
    • Medicare Remittance Easy Print (MREP) Software for Part B Electronic Remittances
  • Online Inquiry Services


EDI Application

The EDI Application Form is used for initial EDI set up.
The information on this form is also used to verify requester information submitted on additional EDI applications.  You must submit a completed EDI Application Form when submitting the EDI Enrollment Agreement or Provider Authorization Form.

  • A Submitter ID number is a unique number identifying electronic submitters. A Submitter ID can be used to transmit Part A, Part B and HHH EDI transactions to your MAC. You must request a Submitter ID if you will be submitting claims directly to medicare.
  • However, if you are a provider and will be using a billing service or clearinghouse to submit your claims, do not complete this form to request a Submitter ID.
  • Billing services, not their customers, need electronic submitter numbers.
  • Providers are not permitted to share their personal EDI access number (Submitter ID) or password because the EDI Submitter ID and password act as your electronic signature; therefore, the provider would be liable if any entity performed an illegal action while using that EDI Submitter ID and password.
  • Likewise, a provider’s EDI Submitter ID and password is not transferable, meaning that it may not be given to a new owner of the provider’s operation. New owners must obtain their own EDI Submitter ID and password.


EDI Enrollment Agreement

  • Every provider who submits electronic claims to Medicare, whether directly or through a billing service or clearinghouse, must complete this agreement.
  • Only one agreement per group is required.
  • EDI cannot process any of the enclosed forms for a provider without first having a completed EDI Enrollment Agreement on file.
  • Providers are obligated to notify Medicare by hardcopy of:
    • Any changes in their billing agent or clearinghouse
    • The effective date of which the provider will discontinue using a specific billing agent or clearinghouse
    • If the provider wants to begin to use additional types of EDI transactions
    • Other changes that might impact their use of EDI

Please Note: The binding information in an EDI Enrollment Agreement does not expire if the person who signed the form for a provider is no longer employed by the provider.


Provider Authorization Form

Every provider who authorizes a billing service and/or clearinghouse to act on their behalf must complete the provider authorization form.
This form must be completed by the provider and submitted with the EDI application.

PC-ACE Pro – 32

  • An electronic claims-entry software that allows suppliers to enter their claims in the HIPAA-compliant ASC X12 837 v5010 format.
  • Pro32 does not integrate into office systems
  • NOTE: Before completing the PC-ACE Pro32 Software Download Form, you must have been assigned a Submitter ID.


  • PCPrint is a software product designed to operate on Windows based personal computers.
  • The PCPrint translator program allows viewing and printing of ASC X12 835 version 5010A1 remittance data.
  • This software does not support systematic auto-posting of the 835 data


Online Inquiry Services



Online Inquiry Services-MAC Portal

MAC portals HHH are free Internet-based, provider self-service portal. The goal is to give the provider secure and fast access to their Medicare information seamlessly via a website. The application provides information access over the Web for the following online services:

  • Eligibility
  • Claims Status
  • Remittances Online
  • Financial Information (payment floor and last three checks paid)

Portals are generally available 24 hours a day, seven days week.
To be eligible to participate, you must have a completed an EDI Enrollment Agreement (included in the packet) that is actively on file. However, an enrollment agreement processed by EDI will not automatically enroll a provider in the portal.


Online Inquiry Services-Direct Data Entry (DDE)

  • HHH claim entry is available directly into the claims processing system via on-line Direct Data Entry (DDE).
  • Access is available to DDE through approved Network Service Vendors (NSVs).
  • Providers use DDE for claim submission by signing in to the claims processing system and entering claims on-line.
  • DDE is also available to all providers who use other methods of electronic claim submission but wish to check status of claims, beneficiary eligibility and correct claims on-line through the DDE system.
  • Each user must have an individual DDE number. For security reason, you cannot share your DDE ID Number, nor can the ID be transferred to another person. If that individual leaves your company or no longer needs access, please contact EDI to delete the ID. One DDE or ID can access multiple provider numbers.


EDI Packet$File/EDI_Enroll_AB_Pack.pdf


NSV Vendors for Palmetto



The medical billing software on your desktop creates the electronic file (the claim) also known as the ANSI-X12 837 file, which is then sent (uploaded) to your clearinghouse account. The clearinghouse then scrubs the claim checking it for errors (arguably the most important thing a clearinghouse does); and then once the claim is accepted, the clearinghouse securely transmits the electronic claim (very important) to the specified payer with which it has already established a secure connection that meets the strict standards laid down by a HIPAA.

The best clearinghouses offer high value features that provide a whole new level of claim intelligence for revenue cycle management that makes their services extremely compelling from a financial perspective, and also make it highly desirable from an office-staff efficiency point of view.

Going Electronic

  • Electronic claims clearinghouses were devised by Medicare and large insurance payers to step in electronically where the postal service was unable to; to pre-screen for claim errors and act as air traffic controllers so to speak of electronic claim submissions.
  • clearinghouses are aggregators (senders and receivers) of mountains of electronic claim information almost all of which is managed by software.
  • clearinghouses offer medical billers and billing managers a way to consolidate all their electronic claims and manage them from a single location, from an online dashboard control panel.


Top 10 Benefits to Look for in a Premium Clearinghouse

  • Eligibility Verification – Determine patient portion before appointment
  • Electronic Remittance Advice (ERA) – Automatically updates Payments & Adjustments
  • Claims Scrubbing – Check claims for errors and verify that it is compatible with the paye
  • Claim Status Reports – Know the status of a claim at all times
  • Rejection Analysis – Have error codes explained in plain English
  • Online Access – Edit and correct claims day or night online
  • Printed Claims – Have claims automatically dropped to paper when necessary but still be able to track and manage them online
  • s – Have your patient statements put on ‘autopilot’ at a cost less than what you can mail them out yourself.
  • Real-time Support – The best clearing houses offer 1-on-1 personal support and training provided by experienced billers.
  • Affordability – When you take into consideration the cost of purchasing forms, the cost of printing, envelopes, postage, and time spent; a clearinghouse ends up costing far less than processing paper claims, plus electronically you have the many added benefits.



  • Allows you to catch and fix errors in minutes rather than days or weeks
  • Results in significantly higher claim success –fewer rejected claims.
  • Rapid claims processing: submission can reduce your reimbursement times to under ten days.
  • Submit all your electronic claims in batch all at once, rather than submitting separately to each individual payer.
  • Eliminates the need to manually re-key transaction data over and over at each payer’s website.
  • It provides a single location to manage all your electronic claims
  • Vastly improve vendor relationships with insurance carriers.
  • Avoid long wait-times being on hold with insurance companies inquiring about claim errors.
  • If you subscribe to a good clearinghouse, you’ll be speaking with a knowledgeable support person within just a few rings.
  • Shorter payment cycles lead to more accurate revenue forecasts.
  • Reduce or eliminate need for paper forms, envelopes and stamps
  • Plain and simple, using a clearing-house greatly simplifies and speeds up your claims processing.
  • But you may ask (legitimately) “If I can submit my claims directly at a payer’s website for free, why should I pay a clearing house?“
  • ERNs and auto posting
  • Even eligibility


Advantages of Going Direct

  • Ability to submit claims directly to the payer without a middleman.
  • Free claims.
  • No recurring fees.

Disadvantages of Submitting Direct to Payers

  • Human error
  • Puts an extra, unnecessary burden on billing staff
  • Lack of centralization
  • Hidden costs
  • Unnecessarily added confusion of multiple accounts to log into, and multiple data entries, which increase the opportunity for errors.
  • Lost claims and a lack of essential tools required for efficient claim management.
  • Little or no support.
  • Maximum Risk to the Revenue Cycle with little or no offsetting benefit.


Different Clearinghouses

  • Waystar
  • Apex EDI
  • eSolutions
  • Claim MD
  • PracticeSuite
  • Gateway EDI
  • ENS Health
  • RealMed
  • Availity (free)
  • Emdeon
  • MD-Online/MCC
  • RelayHealth
  • Ingenix
  • Ability
  • NHS Net Healthclaims
  • Datatrans Solutions