Electronic Claims Processing - EDI for HIPAA

Effective September 30, 2003, Gateway Health Plan's sole electronic claims clearinghouse is WebMD. Gateway Health Plan^® will no longer accept electronic claims from Data Stream, the EDI clearinghouse sponsored by Highmark. Providers currently using Data Stream should contact WebMD at 1-800-845-6592 or http://www.webmdenvoy.com to enroll. It takes about 45 days to enroll in the program. WebMD does not charge providers a transaction fee for claims submitted to Gateway Health Plan^® in the 837 V4010A format.

If you currently bill Gateway Health Plan^® using a paper claim, you can improve your cash flow by submitting electronically. To bill Gateway Health Plan^® electronically, you must be enrolled with WebMD. Please contact WebMD at 1-800-845-6592 to enroll.

Gateway Health Plan is pleased to announce that effective December 08, 2003, providers may begin receiving electronic claims remittance advice (ERA). WebMD will again be the sole clearinghouse for Gateway Health Plan. Providers must be contracted with WebMD to receive a Gateway Health Plan^® ERA. Please contact WebMD or your software vendor for WebMD’s Provider ERA Setup Forms.

HIPAA INFORMATION:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that Gateway Health Plan^® comply with the mandated electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services.

Please use the HIPAA Implementation Guides for the corresponding transactions. The Implementation Guides can be found at Washington Publishing Company's website and downloaded free of charge http://www.wpc-edi.com/hipaa/HIPAA_40.asp. Additional information regarding the standards for electronic transaction are available at the Department of Health and Human Services website.

SETUP AND QUESTIONS:

• ENVOY's Payor Code for Gateway Health Plan: 25169
• Gateway Health Plan's tax identification number is: 25-1691945
• Providers must use the Gateway Health Plan's five (5) or seven (7) digit provider identifier.
• Providers must use the Gateway Health Plan^® eight (8) digit Gateway Health Plan^® member identification number or the ten (10) digit Medical Assistance Recipient number.
• NOTE: Include leading zeros as needed.
• Electronic submissions may be sent at any time 24 hours a day, 7 days a week.
• Electronic claim remittance advice transactions will be sent to WebMD on a weekly basis.
• Contact WebMD at 1-800-845-6592 to enroll for electronic claims submissions, electronic claim remittance advice or to discuss any problems that you have with reports from WebMD.
• Contact Gateway Health Plan's Provider Servicing Department at 1-800-392-1145 if you have any questions related to your claim. Please be sure to have the following information available:
  • Gateway Health Plan's Provider identification number
  • Gateway Health Plan's Member identification number
  • Claim number
  • Envoy/NEIC Report R022 – Provider Daily Statistics
  • Envoy/NEIC Report R026 – Daily Acceptance Report By Provider
  • Envoy/NEIC Report R059 – Unprocessed Claim Report

Please send only HIPAA 837or 835 Companion Document questions to Gateway HIPPA Contact. Please contact your Provider Relations Representative with any other questions that you may have.