Electronic claim process in Medicare overview

Electronic Claims


As of October 16, 2003, all providers and suppliers must submit claims electronically via Electronic Data Interchange (EDI) in the Health Insurance Portability and Accountability Act format, except in limited situations.

Electronic versions of Centers for Medicare & Medicaid Services (CMS) claim forms can be found at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp on the CMS website. Each provider or supplier must complete a CMS Standard EDI Enrollment Form and send it to the Medicare Contractor prior to submitting electronic media claims (EMC). A sender number, which is required in order to submit electronic claims, will then be issued. An organization that is comprised of multiple components that have been assigned Medicare provider identifiers may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which these identifiers have been assigned.


Where to Find Additional Information About Electronic Billing and Electronic Data Interchange Transactions
Additional information about electronic billing and EDI transactions is available at http://www.cms.hhs.gov/ElectronicBillingEDITrans on the CMS website. The EDI Enrollment Form is available from Medicare Contractors.

Electronic Media Claims Submissions
Claims are electronically transmitted to the Medicare Contractor’s system, which verifies claim data. This information is then electronically checked or edited for required information. Claims that pass these initial edits, also called front-end or pre-edits, are processed in the claims processing system according to Medicare policies and guidelines. Claims with inadequate or incorrect information may:

Be returned to the provider or supplier for correction;

Be suspended in the Contractor’s system for correction; or

Have information corrected by the system (in some cases).

A confirmation or acknowledgment report, which indicates the number of claims accepted and the total dollar amount transmitted, is generated to the provider or supplier. This report also indicates the claims that have been rejected and reason(s) for the rejection.



Electronic Media Claims Submission Alternatives


Providers and suppliers who do not submit electronic claims using EMC may choose to alternatively submit claims through an electronic billing software vendor or clearinghouse, billing agent, or by using Medicare’s free billing software. Providers and suppliers can obtain a list of electronic billing software vendors and clearinghouses as well as billing software from Medicare Contractors.