Electronic claim response files
Anthem uses Availity as our exclusive partner for managing all electronic data interchange (EDI) transactions.
When your organization’s claims are submitted either by your clearinghouse/vendor or submitted directly using practice management software, it’s important to review and utilize all responses to understand where your claims are in the adjudication process and if any action is required.
Below is a summary of the process for electronic files, and the response reports that are returned by Availity:
Electronic file is submitted to Availity
- Availity acknowledges receipt of file and validates for X12 format in a series of responses.
- The series of initial responses indicate whether an electronic file was successfully received in correct format and accepted by Availity.
- If errors occur, the impacted file will require resubmission to Availity.
- If your organization uses a clearinghouse/vendor, they are responsible for reviewing these response files.
HIPAA and business validation
- Electronic Batch Report (EBR) - This response acknowledges accepted claims and identifies claims with a HIPAA and business edits prior to routing for adjudication.
- Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the (835) Electronic Remittance Advice. (Edit examples include - Invalid subscriber ID for the date of service and invalid billing and coding per industry standards.)
- Clearinghouse/vendors may provide their own version of this report to your organization.
Availity routes claims to payer
- Delayed Payer Report (DPR) - This response file contains an additional level of editing by the membership adjudication system.
- Currently this response is returned only for Medicare/ Medicaid lines of business.
- Commercial lines of business will return this response in the future - look for forthcoming communications with the details.
- Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the (835) Electronic Remittance Advice.
- Clearinghouses/vendors may provide their own version of this report to your organization.
If you have further questions on the response reports, please contact Availity at 800-282-4548.
July 2021 Maine Provider News