5101:3-1-20.1   Electronic Data Interchange (EDI) Trading Partner Definitions and Criteria to Enroll as an EDI Trading Partner

Effective Date: May 23, 2007

Most Current Prior Effective Date:   November 15, 2004

(A)      Definitions.

(1)      "Trading partner", as defined by the department, is is defined as a covered entity (CE) that submits electronic transactions in its role as an eligible provider for purposes directly related to the administration or provision of medical assistance provided under a public assistance program.

(2)      "Covered entity" (CE), as defined by 45 CFR C.F.R. 160.103 (rev. 2/2006), is a health plan, a health care clearinghouse, or a health care provider that transmits health care information in an electronic format in connection with a transaction covered by this rule.

(a)      "Health plan" is defined as an individual or group health plan that provides, or pays the cost of, medical care.

(b)      "Health care clearinghouse" is defined as an entity that:

(i)        Processes health information received from another CE in a non-standard format or a format containing non-standard data into standard data elements or transactions; or

(ii)       Processes health information received in a standard format into a nonstandard format for another CE.

(c)       "Health care provider" is defined as a provider of medical or health services, and any person or organization who furnishes, bills for, or is paid for health care services in the normal course of business.

(3)      "Eligible provider" is defined as a Medicaid provider that is eligible to render covered Medicaid services as defined in rules 5101:3-1-17, 5101:3-26-04, and 5101:3-3-02 of the Administrative Code.

(4)      "Electronic data interchange (EDI) transactions" are defined as transactions developed by standards development organizations (SDOs) recognized by the centers for medicare and Medicaid services (CMS) and adopted by the department.the Ohio Department of Job and Family Services (ODJFS). The different EDI transactions are defined as follows:

(a)      ANSI X12 820 premium payment is a transaction used to make a payment and/or send a remittance advice.

(b)      ANSI X12 834 monthly member roster or enrollment/disenrollment in a health plan is a transaction used to establish communication between the sponsor of the insurance product and the payer.

(c)       ANSI X12 835 health care claims payment/remittance advice is a transaction used to make a payment and/or send an explanation of benefits (EOB) remittance advice.

(d)      ANSI X12 837 health care claim is a transaction used to submit health care claim billing/encounter information, or both, from providers (institutional, professional, or dental) of health care services to payers, either directly or via clearinghouses.

(e)      ANSI X12 270 eligibility, coverage, or benefit inquiry is a transaction used to inquire about the eligibility, benefits or coverage under a subscriber's health care policy

(f)       ANSI X12 271 eligibility, coverage, or benefit information response is a transaction used to communicate information about, or changes to, eligibility, benefits, and/or coverage.

(g)      ANSI X12 276 health care claim status request is a transaction used to request the status of a health care claim.

(h)      ANSI X12 277 health care claim status notification is a transaction used to respond to a request regarding the status of a health care claim.

(i)        ANSI X12 278 health care services review information request and response is a transaction used to transmit health care service information for the purpose of referral, certification/authorization, notification, or, reporting the outcome of a health care services review.

(B)      Entities meeting the definition of a trading partner as defined in paragraph (A)(1) of this rule may enroll and submit EDI transactions recognized by the department ODJFS once they are issued a trading partner number, complete the trading partner profile form, and sign a trading partner agreement as stipulated in accordance with rule 5101:3-1-20.2 of the Administrative Code. Trading partners must pass the EDI testing process and be approved for EDI production processing prior to submitting Medicaid claims for payment.

(C)      Only trading partners eligible to submit or receive the 837/835 and/or 834/820 transaction sets are eligible to submit and receive the 270/271 and 276/277 transaction sets.

Effective: 05/23/2007

R.C. 119.032 review dates: 03/06/2007 and 05/01/2012

Certification: CERTIFIED ELECTRONICALLY

Date: 05/11/2007

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 11/15/04