EDI Transaction Information

GENERAL OVERVIEW

All Optima Health Companion Guides are to be used with the HIPAA-AS Implementation Guide.  The HIPAA Implementation guides provide comprehensive information needed to create each ANSI transaction set.  The Optima Health Companion Guide is used in conjunction with the HIPAA Implementation Guide; it is intended to clarify issues where the HIPAA Implementation Guide provides options or choices to be made. 

 Download the HIPAA Implementation Guide

BUSINESS USE

• Each EDI vendor will have to sign a Trading Partner Agreement.
• Each transaction set will be used to expedite the execution of electronic information pertaining to a health encounter.
• To accelerate the processing and payment of a claim or encounter.
• The 837 transaction may be sent daily with a disposition report available the next business day.  The disposition report replaces the 997 Acknowledgement File.
• The 835 transaction will contain Remittance Information as well as Electronic Funds Transfer (EFT).  We can not separate the two.
• The 835 will be transferred on a calendar basis.  Vendors will receive a calendar monthly stating when their 835 information will be available.
• Vendors may elect to receive EFT/ERA from Optima Health directly, as long as they can receive data files in the HIPAA compliant ANSI 835 format.

EFT Payment Schedule

The following information summarizes Optima Health's general payment schedule. In cases where our offices are closed, such as holidays or extremely severe weather, the scheduled paymentswill be processed on the next business day. While we cannot foresee every circumstance, our professionally trained staff will make every effort to adhere to the following payment schedule:

Weekly Payment Processing schedule:

Monday - All commercial (fully funded) and government employer groups excluding Federal employee groups.

Tuesday - Optima Behavioral Health & Self-Funded employer      groups (see note 1)

Wednesday - Federal employee groups and Self-Funded employer groups (see note 1)

Payments processed monthly:

• Provider Capitation and Practice Management payments are processed on or before the 15th of every month.
• All remaining payment types not already listed will be processed on or before the 20th of each month.

For providers who choose to receive their payments electronically, funds are normally deposited 24 hours after the payments are processed. Associated electronic remittance advices are usually transmitted 48 hours after payments are processed.  All other providers will receive paper checks/remittances through the US postal system. (see note 2)

Note 1: While claims payments are processed on these days, funds are not released until the payments are funded by their associated employer group. This applies to Self-Funded employer groups only.

Note 2: While Optima Health will make every effort to adhere to the payment schedule, the availability of funds is also dependent on the provider's banking institution.

CONNECTING WITH OPTIMA HEALTH

Optima Health utilizes an FTP solution to allow hosting of a secured FTP site or connecting to an outside FTP site.

There are two URLs Optima Health utilizes for hosting a secured FTP site. See the options listed below that are available for vendors to access the FTP site.

Option 1: File Transfer using an FTP client software

Use the following address to access the FTP site: sftp.sentara.com

There are several FTP clients available for vendors to use. Some examples of FTP client software are WS_FTP, CuteFTP, FileZilla. By choosing this option, the vendor must provide their own FTP software and be familiar with using it.

Option 2: File Transfer using a Web browser

Use the following address to access the FTP site: https://sftp.sentara.com

This option requires the vendor to access the above site using a Web browser (i.e., Internet Explorer). 

Once the site is accessed, the following will occur:

1)  A window to enter the User name and password will display -- see below.

2)  After the proper credentials are entered, the Web Transfer Client window will display, see below.  The Web Client allows access to the vendor's local source and a remote source (Optima Health site).

Electronic Transaction Questions

Please contact us.

TESTING

Once a Trading Partner Agreement is signed and the method of transferring files determined, test files may be submitted to Optima Health. 

• Inbound transaction will be tested with Claredi to ensure transactions are valid and compliant.
• 837 claims must have valid Optima Health member ID numbers and Optima Health provider ID numbers.
• Optima Health will work will all trading partners to identify and eliminate errors.
• The Electronic Funds Transfer/Electronic Remittance Advice implementation timeline is dependent on the trading partners ability to test the receipt and distribution of the EFT/ERA data files. 
• Testing is expected to take no more than 2 months to complete.
• Optima Health will notify trading partner that transaction testing is complete and schedule a mutually agreed upon date to move the transaction to production.
  

Quick Links

Forms

 EDI Setup form - Providers (PDF)

Companion Guides

 HIPAA Transaction Standard Companion Guide 835 - Health Care Claim Payment /Advice

 HIPAA Transaction Standard Companion Guide 837 Professional - Commonly referred to as the HCFA 1500

 HIPAA Transaction Standard Companion Guide 837 Institutional (UB92)

 HIPAA Implementation Guide