So, you’re contracted with Medicare, and now you’re all ready to start treating beneficiaries and shipping claims off to CMS—right? Well, not quite. There’s one more thing you—or your biller—must do: complete your Electronic Data Interchange (EDI) enrollment.
Not sure where to start? Fear not! Here’s everything you need to know about the EDI enrollment process:
What is an EDI?
Sometimes referred to as an 837 file, “EDI” typically refers to the electronic version of a CMS 1500 form. An EDI can pass through multiple specific clearinghouses before arriving at the payer destination—kind of like a post office. After receiving an EDI, the payer also passes information—such as Electronic Remittance Advices (ERAs), which are the electronic version of Explanations of Benefits (EOBs)—back to the provider via the clearinghouse.
What is EDI enrollment?
EDI enrollment is the process of getting permission to submit claims through a specific clearinghouse. Several payers (including Medicare) require providers to complete EDI enrollment before they will accept any claims. Though not all payers require this enrollment, if you haven’t completed the enrollment process before submitting a claim to one that does, then the payer will reject the claim.
Unlike EDI enrollment, every payer requires ERA enrollment in order to send ERAs to the provider. If you do not complete ERA enrollment, you will receive paper EOBs from the payer. The ERA enrollment form is often included with the EDI enrollment form, and approval can take anywhere from a few days to a few weeks. You can begin processing claims electronically before your ERA enrollment has been approved; however, you may need to manually post some EOBs to your billing software.
Electronic Funds Transfer (EFT) enrollment—sometimes called “ACH enrollment”—allows for the electronic transmission of funds from the payer to the provider as reimbursement for patient services. While you can opt to have your reimbursements delivered by check, you’ll typically receive funds faster with EFT enrollment. This process varies by payer, so you’ll need to reach out to the entity directly to confirm how to enroll.
Enrollment vs. Credentialing
You may occasionally hear the terms “enrollment” and “credentialing” used interchangeably. In fact, these two processes are totally separate. As Meredith Castin, PT, DPT, founder of The Non-Clinical PT, explains here, “Credentialing is the process of becoming accepted into an insurance provider’s preferred network.” Castin goes on to explain that this process “helps insurance carriers (including Medicare and private payers) determine that you’re qualified to serve on their panels, which, in turn, helps you attract patients to your practice.”
How should rehab therapists complete EDI enrollment?
While the process may vary somewhat from payer to payer, here are a few things for PTs, OTs, and SLPs to consider when completing EDI enrollment:
- You can complete EDI enrollment online or by filling out a paper form. Head to the payer’s website for more information or to obtain a copy of the form.
- To complete the form, you’ll need:
- your practice’s business address and phone number,
- a business email,
- the contractor code, and
- all relevant PTAN/NPI numbers.
- You’ll need to be credentialed with the payer prior to completing your EDI enrollment. (Note that credentialing is not the same as contracting. Click here to learn the difference.)
- Enrollment is based on the NPI on file with the payer. This may be either the default billing provider NPI or rendering provider NPI, depending on how you are credentialed with the payer. (Note: Each billing provider must complete EDI enrollment in order to submit claims.)
As you can see, completing your EDI enrollment is nothing to stress about, but doing so in a timely manner ensures that you’ve got money in the bank—or at least that you can get money in the bank sooner rather than later. Have questions about EDIs, ERAs, or insurance credentialing? Drop us a line in the comment section below!