EDI Update - FFS Claim Denials for Provider/Submitter Mismatch Begin 1/1/2017

Oregon Health Authority and Oregon Department of Human Services sent this bulletin at 12/30/2016 01:25 PM PST

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Electronic Data Interchange Update

Beginning January 1, 2017, OHA will deny claims submitted by EDI submitters who are not listed on the billing provider’s Trading Partner Agreement with OHA.

  • The paper remittance advice will list the denial reason using Explanation of Benefit code 9013 (Provider and submitter mismatched).
  • 835s will list the denial reason using Adjustment Reason Code 223 and Remark Code N407 (You are not an approved submitter for this transmission format).
  • The Provider Web Portal will list Adjustment Reason Code 223.

To avoid these denials, the billing provider must report their current EDI submitter by completing and mailing the new two-page Trading Partner Agreement (OHA 2080) to OHA. You can find this form at https://aix-xweb1p.state.or.us/es_xweb/DHSforms/Served/le2080.pdf.

To learn more about how to complete this form, read our line-by-line instructions at http://www.oregon.gov/oha/healthplan/tools/How to Complete the Oregon Medicaid Trading Partner Agreement.pdf.

If you have any questions, please email us at DHS.EDISupport@state.or.us.