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The Ohio Department of Aging

Ohio Department of Aging How EDI Works in PIMS

Here is an example of how EDI is implemented within the Department of Aging's PIMS computer system. Each provider wanting to use the EDI function must go through a testing phase prior to submitting EDI claims. In this example a provider is billing for services they rendered to a consumer.

  • Provider completes the Trading Partner Profile (TPP) and Trading Partner Agreement and forwards them to ODA for processing. The Trading Partner Profile will be available as an on-line form but the Trading Partner Agreement must be mailed in.
  • ODA updates the PIMS provider record to reflect information listed in the TPP and forwards the document to ECC to set up EDI translator Partner Profile and electronic mailbox.
  • ECC communications representative calls the primary contact identified in the ODA TPP to introduce himself and set up communication and identification requirements.
  • The provider then performs a communication test with ECC to test the connections and ensure both parties can send and receive data.
  • Once the communications tests are completed, ECC notifies ODA EDI Coordinator who then schedules document testing. Purpose of document testing is to prove that trading partner can consistently generate a proper ODA 837 Claim. This testing phase may last between 1 to 2 months depending on the problems encountered.
  • Once the provider has successfully exchanged EDI transactions with ODA, the EDI Coordinator notifies the provider, the PAA, ECC, and ODA of the scheduled date of production roll-out.
  • The provider then transmits a file to their assigned mailbox. In terms of EDI, this file is the 837 Claim: Professional transaction set.
  • The translator will then send the provider a 999 Functional Acknowledgment and (if provider has indicated they can receive it) a 277 Claim Acknowledgment. A 277 Claim Acknowledgment is only created if there is a rejection of all or partial data.
  • ODA's system is set up to automatically poll the directory where the translator places the files. When the system finds a file, it performs an edit before loading it into PIMS so the PAA can process the payment.
  • The PAA then adjudicates the claims and will address suspensions, as they currently do.
  • Once adjudication is complete, the PAA performs the remittance advice process. If provider has indicated in the TPP that they can receive an 835 Claim Payment/Advice transaction, the system will create an 835 text file.
  • The 835 text file is sent to the ECC for conversion by the EDI translator into EDI format. A paper remittance advice is created for the PAA and, if requested, for the provider too. Physical check preparation and distribution is unchanged and handled by the PAA.
  • When the EDI translator receives the text file from ODA, they create an EDI formatted file and place it in the provider's outbound documents folder (mailbox) where the provider can retrieve it.