Electronic Healthcare Transactions System: 837 Health Care Claims Submissions (Institutional or Professional), 270 Health Care Eligibility Benefit Inquiries, 276 Health Care Claims Status Requests and 834 Benefit Enrollment and Maintenance

All our EDI Solutions are NPI COMPLIANT


Proven Solution for Claims EDI and All Other Electronic Transaction Formats 

Proven HIPAA compliant solution for electronic claims submissions

EHTS System Overview

EHTS HIPAA Engine

EHTS Certification Process

EHTS Implementation

Proven Solution for Claims EDI and All Other Electronic Transaction Formats


Convert, process and transmit all transaction formats using automated batch process. EHTS converts, processes and transmits electronic claims submissions – and all other electronic healthcare transmissions – directly to any government or commercial payer in the required transaction format. EHTS functions without using or requiring a clearinghouse’s services.

Reliable and cost-effective. Medical/Health services providers and payers utilize the EHTS software solution to support their billing operations. 

HIPAA compliant. EHTS’s capabilities for processing and transmitting electronic claims, remittances and all other transaction file formats are certified as HIPAA-compliant.

EMS meets mandated requirements for all standard transaction file formats:

• X-12 837 Health Care Claim (submission): Institutional or Professional
• X-12 270 Health Care Eligibility Benefit Inquiry
• X-12 276 Health Care Claims Status Request
• X-12 278 Referral Certification; Service Authorization Request
• X-12 820 Premium Payment for Insurance Products
• X-12 834 Benefit Enrollment and Maintenance
• X-12 997 acknowledgment reports

Proven HIPAA-compliant solution for electronic claims submissions

The most efficient and cost-effective method for submitting HIPAA-compliant electronic claims is to transmit them directly to a payer (e.g., Medicaid or commercial insurer).

EHTS enables providers and insurers to submit claims directly to payers without upgrading their existing system(s), using a clearinghouse or acquiring another vendor application. The system includes a standard interface enabling different or non-HIPAA compliant claims formats to be extracted, examined, converted and transmitted to payers in HIPAA-compliant transaction formats.

EHTS enables providers to:

• Import non-compliant claims data content and format
• Convert content and format to meet compliance requirements
• Directly submit electronically to each payer/destination
• Report on data that is imported and submitted

Whether an in-bound or out-bound format, all claims information is directed towards the destination payer.

EMS furnishes all services associated with certifying providers to each of their payers for submission of HIPAA-compliant claims. EMS also provides a simple application that tracks all activities related to the process.

EMS’s EHTS system converts the following non-HIPAA compliant claim formats to the X12-837 4010 claim format:

• NY Medicaid Claim Form A, B and C
• HCFA 1500 print image
• National Standard Format 1500 version 2.1
• UB92 print image
• UB92 electronic version 5
• Other standard EDI formats
• Proprietary data sets

Using secure and encrypted data communications, EHTS automatically transmits HIPAA-compliant claim files directly to the submitter’s payers.

EHTS System Overview

EHTS receives a batch of electronic claims that are generated from the client’s existing/legacy information system. EHTS then analyzes each claim to determine whether all data field requirements are met.

All claims that pass the edits are:

• Separated by payer class and transaction type
• Formatted into unique transmission batches
• Transmitted directly to the payer according to a pre-determined schedule or manually

Audit reports are produced for each phase of the process.



Existing/Legacy Information System

EHTS begins with the client’s base information system that contains patient and claims data. Non-HIPAA compliant claims are generated.

Certain non-HIPAA compliant claim formats require additional information to be loaded into an “ancillary” file. Information that is specific to the submitting entity exists in a profile database and is automatically incorporated to build the HIPAA-compliant claim file.

HIPAA Engine

EHTS’s HIPAA Engine is a series of software programs that perform the following functions:

• Data field validation – verifies readability and format
• Data content validation – verifies required fields and applicable content
• Conversion of accepted claims into the HIPAA compliant X12 837 Version 4010 format
• Creation of individual claim submission batches by payer and claim type
• Generation of Accepted Claim Report
• Generation of Rejected Claim Report

The EMS HIPAA Engine is managed and operated through simple interface screens. Users select options from menus and run-time display screens.

Secure Claims Submission Module

Once the individual claim submission batches are generated, the EHTS transmits each batch using an automated schedule via the secure and encrypted “communications gateway.”

The communications gateway is developed according to the resources and technology available to the provider office/submitter taking into account the payer’s capabilities to receive claims and HIPAA-compliance.

The EHTS Secure Claims Submission Module generates a Submission Report.

Certification Process

EMS collaborates with the client's office to achieve certification for the direct submission of HIPAA-compliant claims.

EMS performs the following activities:

• Verifies enrollment for all provider ID and submitter combinations
• Creates an EHTS account for login and financial accounting
• Reviews sample electronic claims output to verify format types and to ensure that basic requirements are met
• Determines method to bridge gaps for required fields, etc.
• Completes custom programming (if required)
• Conducts a test submission
• Collaborates with client until HIPAA certification is secured/approved

Implementation

• All certification activities as described above
• Installation of a network workstation that has direct access to the information system
• Custom configuration of the network workstation so that access to EMS and the communications gateway is established
• Live testing of HIPAA-compliant claims once EHTS is installed and the submitter is certified for all entities
• User training and documentation 

Additional Considerations

• EMS maintains and supports the EHTS system from its office located in Clarence, NY.
• Routine usage questions and software fixes are regarded and addressed as high priorities.
• Updates are incorporated into new EHTS releases.