HIPAA EDI Implementation

1. Northwood accepts electronic claims.
2. Northwood will continue to accept paper claims and will phase out paper claims at a subsequent date after Northwood and its provider network has successfully made the transition to electronic claims.
3. Northwood will accept HIPAA X12 837 5010-A1 professional healthcare claim formatted transactions.
4. Northwood has implemented a secure FTP site that will be utilized for the data exchange and the electronic claim processing that is being provided at no charge to providers.

Providers will initiate the secure FTP session from their Internet connection. Providers will control the session and be responsible for initiating the sending and receiving of data.  Secure FTP client software is available for most information system platforms.

Some of the Free SFTP programs available include:
PUTTY SFTP (Windows command line based software)
Core FTP Lite (Windows interface SFTP software)

5. Currently, Northwood is not registered to receive electronic claims through healthcare EDI clearinghouses.
6. Only providers that are members of the Northwood provider network may exchange EDI with Northwood.
7. Providers must be registered to service a specific Northwood contract in order for Northwood to accept claims from that provider for that contract.
8. Providers will be able to send electronic claims for the Northwood contracts listed under number 11.
9. Currently, Northwood will accept paper claims (HCFA 1500) only for the ACCI and Aetna contracts.
10. Providers will use their Tax Id number to identify themselves within data exchanges where required. Northwood will use the same identifier for Provider where necessary.
11. Northwood Contract Codes are as follow:

• Claim provider numbers and pre-authorization provider numbers must match.
• Providers filing claims electronically are required to agree to the Northwood electronic claim processing audit process where Northwood may request supporting documents prior to and after claim processing. Details of the audit process will be made available after a provider submits the Northwood provider electronic claim processing application.
• Providers will still be required to submit Medicare explanation of benefit statements for Medicare supplemental claims. At this time Northwood would prefer that providers submit Medicare supplemental claims on paper.
• Northwood and its providers will use 383064979 to make reference to Northwood, Inc. within data exchanges where required.
• Providers filing claims electronically will not be required to submit paper documentation for physician prescriptions, certificates of medical necessity and other supporting documents.
• Currently, Northwood will continue to process and mail to providers’ paper rejection notices and payment vouchers.
• Northwood subscribers and dependents need to be identified by their insurance contract number, in field NM109 in loop 2010-BA Subscriber Name.  Social Security numbers if available should be provided in REF02 in loop 2010-BA Subscriber Secondary Identification.

Auto Club Group claims need to submit the Auto Club Group case number in field NM109.  Social Security numbers, if available for Auto Club Group, should be provided in REF02 in loop 2010-BA Subscriber Secondary Identification.

1. Northwood prior authorization numbers are required to appear in loop 2300, Claim Information, for electronic claims for Northwood contracts and plans that currently require them.  Northwood will be unable to process electronic claims that do not have prior authorization numbers when they are required.
2. Northwood Providers will be required to submit electronic claim processing application forms.  Once the electronic claim processing application has been accepted security information will be exchanged and test transmissions will be scheduled.