Understanding Payer Enrollment for Electronic Transactions

If you’re getting started with Office Ally’s EDI tools or preparing to submit claims electronically, it’s important to understand how payer enrollment works for different transaction types.

Before We Begin:

To use Office Ally’s electronic features—such as submitting claims, checking eligibility, or receiving ERAs—some Payers may require you to complete payer-specific enrollment for each type of EDI transaction.

Note: Some payers require separate enrollments for each type of transaction. Submitting claims, checking eligibility, and retrieving payment info may all have different enrollment steps.

What is an EDI Transaction?

EDI (Electronic Data Interchange) allows healthcare providers and insurance payers to securely exchange key billing and administrative data in a standardized digital format. It replaces paper-based workflows with faster, more accurate, and more secure communication.

Common EDI Transactions:

Below are the four most common EDI transactions used in the healthcare billing process:

1. Claim Submissions (ANSI 837):

• Submit healthcare claims (Professional, Institutional, Dental) electronically.

• Replaces paper claim forms with faster, automated processing.

2. Electronic Remittance Advice (ERA – ANSI 835):

• Provides payment details including amounts, denials, adjustments, and patient responsibility.

• Think of this as the digital version of an Explanation of Benefits (EOB).

3. Eligibility and Benefits (ANSI 270/271):

• 270: Your request to verify coverage.

• 271: Payer’s response, confirming eligibility and benefit details.

• Helps reduce denials and billing surprises by checking before a visit.

4. Claim Status Inquiry and Response (ANSI 276/277):

• 276: Your request to check a claim’s status.

• 277: Payer’s response with current processing details.

• Reduces follow-up phone calls to payers.
  

Why Enrollment Matters:

Each payer sets its own requirements. Some don’t require any enrollment, some only require claim submission enrollment, while others also require separate enrollments for eligibility, ERAs, or claim status.

Tip: If enrollment isn’t completed, claims may be rejected, or you may not receive eligibility responses or remittance advice.

Next Steps: Getting Started with Enrollment:

1. Go to the Office Ally Payer List by clicking Resources > Payers List from the Office Ally Homepage

2. Search for the payer you plan to work with. Once you’ve found it, click Resources again, and in the dropdown click Payer Claims/Eligibility/Claim Status Enrollment Instructions.

3. Review and complete the enrollment requirements for each EDI transaction you want to use.

You’ll find specific instructions and forms (if needed) in the forms listed in the Payer Claims/Eligibility/Claim Status Enrollment Instructions page to complete the setup successfully. We recommend checking enrollment requirements before submitting any EDI transaction to avoid delays.