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Senior Whole Health - 5010

• SWH of MA Companion Guide

 *Please Note: This information is supplied for informational purposes only. Senior Whole Health does not guarantee the accuracy of these documents.

Types of EDI Transactions

Electronic Data Interchange (EDI) functionality is utilized by SWH of MA to complete several types of ASC X12N Version 5010 transactions, including:

• Claims Submission (837 Professional and Institutional Healthcare Claims)
• Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) – (835 Healthcare Claim Payment/Advice)
• Referral Certification and Authorization (278 Healthcare Services Review - Request for Review and Response)
• Eligibility for a Health Plan (270/271 Healthcare Eligibility Benefit Inquiry and Response)
• Claims Status (276/277 Healthcare Claim Status Request and Response)

EDI Claims Submission

The easiest way to submit EDI claims to Senior Whole Health is through a Clearinghouse. You may submit the EDI claims through your own clearinghouse or use SWH’s contracted clearinghouse (see the Clearinghouse Information section for Payer ID information). If you do not have a Clearinghouse, SWH of MA offers additional electronic claims submissions options. Log on to Availity's Provider Portal for additional information about claims submission options available to you.

270/271 Healthcare Eligibility Benefit Inquiry and Response & 276/277 Healthcare Claim Status Request and Response

SWH of MA does not directly exchange 270/271 and 276/277 transactions. The 270/271 and 276/277 transactions are handled by SWH’s contracted clearinghouse Change Healthcare. The transactions may be sent directly to Change Healthcare or via your own clearinghouse.

EDI Forms

278 Referral Certification and Authorization Form

The 278 Request transaction is utilized to verify medical necessity for health care services; therefore, additional supporting documentation may be necessary for approval of requested services.

278 - Request for Review and Response

• CMS: Centers for Medicare & Medicaid Services  
• Wedi-Snip: Workgroup for Electronic Data Interchange - Strategic National Implementation Process
• WPC: Washington Publishing Company

State/Commonwealth Links

• Massachusetts Department of Medical Assistance Services
  
  
  

Can I submit COB claims electronically?
Yes, SWH of MA and our connected Clearinghouses fully support electronic COB.

Do I need to submit a certain volume of claims to send EDI?
No, any number of claims via EDI saves both time and money.

Which Clearinghouses are currently available to submit EDI claims to Molina?
See Clearinghouses section.

What claims transactions are currently accepted for EDI transmission?
837P (Professional claims), 837I (Institutional claims).

Where can I find more information on the HIPAA transactions?
See companion guides and State Guide sections

How do I exchange the 270/271 Eligibility Inquiry?
SWH of MA does not directly exchange the Eligibility transactions. The transactions may be sent to SWH’s contracted clearinghouse Change Healthcare to verify Eligibility. *New York Providers will continue to submit transactions through Claimsnet.

How do I exchange the 276/277 Claim Status Inquiry/Response?
SWH of MA does not directly exchange the Claim Status transactions. The transactions may be sent to SWH’s contracted clearinghouse Change Healthcare to verify Claim Status. *New York Providers will continue to submit transactions through Claimsnet.

What do I do if I still have questions?
Contact us (see below Contact Us section).

To submit paper claims, please mail to:

Senior Whole Health
P.O. Box 22640
Long Beach, CA 90801

If you have questions, contact Senior Whole Health at (855) 838-7999

EDI Technical Assistance: Please contact Change Healthcare at (866) 371-9066