Electronic Data Interchange (EDI)
MCC supports our providers, and as such would like to highlight the many benefits of electronic claims submission that will have direct impact on your time! EDI will help:
- Efficient information delivery
- Reduce operational costs associated with paper claims (printing, correlating, and postage)
- Increase accuracy of data
- Ensure HIPAA compliance
MCC works with several claims clearinghouses including:
- Office Ally
- Trizetto Provider Solutions (aka Gateway)
- Allscripts (aka Relay Health)
For more information on EDI, please refer to the MCC provider manual.
Molina Complete Care
*Please Note: This information is supplied for informational purposes only. Molina Complete Care does not guarantee the accuracy of these documents.
Types of EDI Transactions
Electronic Data Interchange (EDI) functionality is utilized by MCC 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 MCC is through a Clearinghouse. You may submit the EDI claims through your own clearinghouse or use MCC’s contracted clearinghouses (see the Clearinghouse Information section for Payer ID information). If you do not have a Clearinghouse, MCC offers additional electronic claims submissions options. Log on to Availity's Provider Portal for additional information about claims submission options available to you.
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
Can I submit COB claims electronically?
Yes, MCC 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 MCC?
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?
MCC does not directly exchange the Eligibility transactions. The transactions may be sent to Molina's contracted clearinghouses to verify Eligibility.
How do I exchange the 276/277 Claim Status Inquiry/Response?
MCC does not directly exchange the Claim Status transactions. The transactions may be sent to MCC’s contracted clearinghouses to verify Claim Status.
What do I do if I still have questions?
Contact us (see below Contact Us section).