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Rev 01.17.2014.1 AVAILITY WEB PORTALWorkers’ Compensation Companion Guide Availity, LLC, all rights reserved. Confidential and proprietary.Page 1 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideTable of ContentsAbout this Guide . 3Disclaimer . 3Overview . 4Definitions . 4Availity Process Flow for Workers’ Compensation eBills . 5Process Diagram . 5Process Steps . 6Submitting eBills through the Availity Web Portal . 8Sample Availity ReceiveFiles Mailbox . 9Submitting Attachments via Fax . 10Helpful Hints . 10Sample Fax Cover Sheet . 10Enrolling to Receive Electronic Remittance Advice (ERA) . 12Setting ERA Delivery Preferences . 12Importing ERA Information . 12Viewing ERAs using the Remittance Viewer on the Availity Web Portal . 13Appendix A – HIPAA and Workers’ Compensation Jurisdictional Usage Analysis . 15Appendix B – Availity Workers’ Compensation Payers List . 17Appendix C – Useful Resources . 17 Availity, LLC, all rights reserved. Confidential and proprietary.Page 2 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideAbout this GuideThe purpose of this guide is to describe the processing of workers’ compensation medical bills via the Availity Health Information Network.DisclaimerAvaility provides the information in this guide for education and awareness use only. While Availitybelieves all information in this document to be correct at the time of writing, the information provided hereis for reference use only and does not constitute the rendering of legal, financial, or other professionaladvice or recommendations by Availity. If you require legal advice, you should consult with an attorney.The listing of an organization in this guide does not imply any sort of endorsement, and Availity takes noresponsibility for the third-party products, tools, and internet sites listed. The existence of a link ororganizational reference in any of the following materials should not be assumed as an endorsement byAvaility. Availity, LLC, all rights reserved. Confidential and proprietary.Page 3 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideOverviewThe Health Insurance Portability and Accountability Act of 1996 (HIPAA) included requirements toestablish national standards for health care transactions. These standards were designed to improve theefficiency and effectiveness of the nation's health care system by encouraging the widespread use of1electronic data interchange (EDI) in health care.Although workers’ compensation programs are not strictly required to comply with HIPAA regulations, theruling does encourage these entities to adopt HIPAA standards when processing medical billselectronically. The Availity Health Information Network facilitates the electronic processing of workers’ compensationmedical bills in accordance with HIPAA standards. This document is designed to help health careproviders successfully submit these transactions.DefinitionseBillThe term “eBill” is used in workers' compensation to refer to an electronic medical bill (claim). The chargefor each episode of care or encounter with an injured employee is considered1a “bill.”eBill AgentAn “eBill agent” facilitates the processing of the workers’ compensation eBills between health careproviders and payers, much the same way a group health clearinghouse facilitates commercial claims. It1can also establish electronic connectivity between the various parties to the transaction.eBill AttachmentsIn workers' compensation, the majority of eBills require additional information, or attachments, before thepayer can adjudicate. An electronic tracking number (attachment control number) provides the link1between the eBill and the attachment.1Content sourced from Workgroup for Electronic Data Interchange (WEDI) Strategic National Implementation Process (SNIP),Electronic Medical Billing White Paper, 2010. Availity, LLC, all rights reserved. Confidential and proprietary.Page 4 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideAvaility Process Flow for Workers’ Compensation eBillsAvaility processes workers’ compensation eBills in the same way it processes other ANSI X12N 8372claims . The same HIPAA validation and editing rules apply.Process DiagramThe following diagram provides a high-level overview of the workers’ compensation process throughAvaility.2X12 is a nationally recognized standard for exchanging electronic data and is maintained by the American Standards Institute(ANSI). It allows organizations with varied computer systems to exchange data electronically in a consistent and standard format. Availity, LLC, all rights reserved. Confidential and proprietary.Page 5 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideProcess StepsThe following steps provide some additional information on the workers’ compensation process throughAvaility.1. The health care provider submits an eBill to Availity via EDI or the Availity secure Web portal. TheeBill must meet all HIPAA and ANSI X12N 837 standards, including the following elements importantfor workers’ compensation: Injured employee, including patient ID Date of injury or accident Employer information Insurance carrier Provider state license number (attending, rendering) Date(s) of serviceNote: See Addendum A – HIPAA and Workers’ Compensation Jurisdictional Usage Analysis formore specifics on HIPAA and workers’ compensation requirements via EDI. See Submitting eBills through the Availity Web Portal later in this document for moreinformation on Web submission.2. Availity applies HIPAA validation and editing rules to the eBill and, if the file is successful, forwardsthe eBill to the eBill agent.3. The eBill agent applies additional validation rules to the eBill, including rules to identify whether thepayer requires eBill attachments. If one or more eBill attachments are required, the eBill agent returnsa file to Availity with a unique fax cover sheet for each attachment request.Note: For more information on fax cover sheets, see Submitting Attachments via Fax later in thisdocument.4. Availity delivers the fax cover sheet file to the provider’s Availity ReceiveFiles mailbox.Note: The provider receives acknowledgements, validation reports, and transaction response files foreBills in the same format and timeframe as other 837 transactions. Providers can access their Availity mailbox either through the Availity secure Web portal (EDI FileManagement Send and Receive EDI Files), or through Availity’s Secured File TransferProtocol (SFTP) interface. See Sample Availity ReceiveFiles Mailbox later in this document formore information. Providers using a practice management system (PMS)/hospital information system (HIS) vendormay not have direct access to the Availity SFTP interface. In this case, the provider shouldcontact the vendor for instructions on how to retrieve these files. Availity, LLC, all rights reserved. Confidential and proprietary.Page 6 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion Guide5. The provider prints the fax cover sheet and sends it via fax, along with the appropriate attachment, tothe eBill agent fax number on the cover sheet.Note: See Helpful Hints later in this document for tips on successful fax transmission. Providers have15 days to submit the required attachments. During this period, the eBill agent sends the followingstatus notifications through Availity until the provider submits the required documentation: Day 01 – Status Claim has been pended; attachments required Day 05 – Status Reminder that claim is still pended Day 10 – Status Reminder that claim is still pended Day 15 – Status Pending period has expired and claim has been rejected6. The eBill agent forwards the eBill and associated attachment(s) to the payer.7. The payer adjudicates the eBill. Some payers also send an 835 electronic remittance advice (ERA) tothe eBill agent, who then sends it to Availity.8. If applicable, Availity delivers the ERA to the provider’s Availity ReceiveFiles mailbox.Note: Providers must complete Availity’s workers’ compensation ERA enrollment in order to receiveERAs through Availity. Not all payers return ERAs. For more information, see Enrolling to ReceiveElectronic Remittance Advice (ERA) later in this document.For more details on sending and receiving EDI files, refer to Availity’s EDI Guide, “Chapter 4: Uploadingand Downloading EDI Files.” Availity, LLC, all rights reserved. Confidential and proprietary.Page 7 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideSubmitting eBills through the Availity Web PortalAvaility provides the option of submitting eBills through the professional and facility claim forms on theAvaility secure Web portal.Note: The process flow for eBills submitted through the Web is the same as it is for EDI. Only thesubmission method differs. See Process Steps earlier in this document for more information.Follow these steps to submit eBills through the Availity Web Portal:1. Log in to the Availity Web Portal and access the appropriate claim form from theAvaility menu: For professional claims, click Claims Management Professional Claim. For facility claims, click Claims Management Facility Claim.2. In the Payer field, select WORKERS’ COMPENSATION. An additional field displays labeledWorkers’ Compensation Payer.3. In the Workers’ Compensation Payer field, select the specific payer to which you are submitting theclaim. Each payer is identified in the list by both payer name andpayer ID.4. Complete the claim form as appropriate.Note: For general help completing the claim, click Help at the top of the claim form page and view theSubmitting Professional Claims/Encounters (5010) topic or the Submitting Facility Claims/Encounters(5010) topic, as needed. For specific help on a field, click the blue question markname where available. Availity, LLC, all rights reserved. Confidential and proprietary.Page 8 of 17 Updated 1/17/2014next to the field
Availity Workers’ Compensation Companion GuideSample Availity ReceiveFiles MailboxThe following image shows an Availity ReceiveFiles mailbox with sample files related to workers’compensation eBills.›PDF Files – Files with a .pdf extension contain the attachment fax cover sheet the eBill Agentreturned for the eBill.›ERA Files – Files with a .era extension contain the 835 ERA the payer returned for the adjudicatedeBill. Workers’ compensation ERA file names begin with ERA-JOPARI SOL. Availity, LLC, all rights reserved. Confidential and proprietary.Page 9 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideSubmitting Attachments via FaxAs outlined in this document, Availity’s current workers’ compensation solution uses a fax-based solutionfor submitting eBill attachments.Each fax cover sheet provided by the eBill agent has a bar code with a variety of data elements, includinga unique attachment control number for tracking purposes. This bar code data allows the payer toassociate each attachment to the correct eBill. In addition, the payer can scan the bar code data to autopopulate the information into the payer’s system.Helpful HintsFollow these tips to help ensure the success of your workers’ compensation fax transmissions.›Place the fax cover sheet in front of the attachment documents and send via fax to the numberindicated on the cover sheet.Note: The fax number may change, so be sure to fax to the number shown on the cover sheet for thespecific claim.›Do not write on the fax cover sheet or otherwise alter it in any way.›Do not place your organization’s own fax cover sheet in front of the fax cover sheet provided by theeBill agent.›Do not send a copy of the eBill.›You may fax multiple cover sheets and associated attachments in a single submission.›To improve the quality of your faxes, ensure your fax machine resolution is set to ‘fine.’Sample Fax Cover SheetThe following image shows a sample attachment fax cover sheet. Availity, LLC, all rights reserved. Confidential and proprietary.Page 10 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion Guide Availity, LLC, all rights reserved. Confidential and proprietary.Page 11 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideEnrolling to Receive Electronic Remittance Advice (ERA)As a registered Availity user, you can enroll your organization to receive ERAs from payers for workers’compensation eBills. Availity recommends providers that submit Workers’ Compensation claims enroll toreceive electronic remittance advice (ERA). ERA transactions may include rejections not shared on otherresponses. Therefore, providers not receiving ERAs are vulnerable to not receiving important rejectioninformation.For your convenience, Availity delivers the ERAs to your Availity ReceiveFiles mailbox.Note: You only have to submit one ERA enrollment form to receive ERAs from multiple participatingpayers on the Availity Workers’ Compensation Payers List. However, not all payers on the list returnERAs. Refer to the ERA (835) column of the list to determine whether a specific payer returns ERAs.Follow these steps to enroll:1. Access the Availity Workers’ Compensation Payers List.2. In the list, locate the payer(s) with whom you want to enroll for ERAs.3. In the row for that payer, refer to the ERA (835) column. If there is an X in the ERA (835) column, the payer returns ERAs. Go to step 4. If there is no X in the ERA (835) column, the payer does not return ERAs. Do not complete thesteps below. You cannot enroll to receive ERAs from this payer.4. Complete the Availity Multi-Payer ERA Enrollment form. Follow the instructions on the form exactly.Missing or incorrect information may result in your enrollment being denied.5. Send the completed form to Availity via e-mail, fax, or 773Availity, LLCP.O. Box 550857Jacksonville, FL 32255-0857Availity will process your enrollment within three to five business days of receipt and send you aconfirmation e-mail once enrollment is complete.Setting ERA Delivery PreferencesYou can set up ERA delivery preferences including file compression, size, grouping (aggregation), anddelivery schedule. To set up or change ERA delivery preferences, click EDI File Management EDIReporting Preferences in the Availity menu, and then click the Claim Payment/Advice tab.Importing ERA InformationYou can import the information from an ERA into most electronic billing systems for automatedreconciliation of accounts receivable. For assistance with importing ERAs into your electronic billingsystem, contact your vendor. Availity, LLC, all rights reserved. Confidential and proprietary.Page 12 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideViewing ERAs using the Remittance Viewer on the Availity Web PortalThe remittance viewer is a revenue cycle management solution available on the Availity Web Portal thatgives you the power to easily search, view, and reconcile 835 ERA data.Note: To view ERAs from a payer for workers’ compensation eBills using the remittance viewer, youmust be enrolled to receive ERAs from that payer. If your ERAs are delivered to another organization (such as a billing service), click Help at the topof the Availity Web Portal and view the Getting Access to Your Organization's ERAs topic. For more information on using the remittance viewer, click Help at the top of the RemittanceViewer page and view the Using the Remittance Viewer topic.Follow these steps to search for ERAs using the remittance viewer:1. Confirm that you are assigned the Claim Status Inquiry role on the Availity Web Portal.Check with your Availity Primary Access Administrator (PAA) if you are unsure.2. Confirm that your workers’ compensation ERA enrollment is complete. See the instructions earlier inthis section for details.3. Log in to the Availity Web Portal and click Claims Management Remittance Viewer in theAvaility menu.4. On the Remittance Viewer page, enter appropriate search criteria to locate the ERA. You can searchby check, patient, or claim.To search for workers’ compensation ERAs only, follow these steps:a. On the Remittance Viewer page, under Optional Search Criteria, click No to the question Do youwant to search for all payers?b. In the Available Payers box, select JOPARI SOLUTIONS and click to move it to the SelectedPayers box. Jopari Solutions is the eBill Agent for Availity. Availity, LLC, all rights reserved. Confidential and proprietary.Page 13 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion Guide5. Click Search. The results page that displays varies depending on whether you searched by check,patient, or claim.Note: JOPARI SOLUTIONS, the name of the eBill Agent, displays in the Payer column ofthe search results page. To see the actual payer name, you must view the check or claim details. Availity, LLC, all rights reserved. Confidential and proprietary.Page 14 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideAppendix A – HIPAA and Workers’ Compensation JurisdictionalUsage AnalysisThe following table identifies variances at the loop, segment, element, and code levels between HIPAAmandated ANSI X12N 837 implementation guides and jurisdictional usage for workers’ l,Institutional2010BA Subscriber HIPAA situationalInformation,N3 Address and N4Workers’ compensationCity State Zipjurisdictionally required;used to convey employerinformationRequired when the patient is not the sameperson as the subscriber.837Professional,Institutional2300 ClaimInformationDTP Date ofAccidentHIPAA situationalRequired when the condition being reportedis related to an accident.Workers’ compensationjurisdictionally requiredAll workers’ compensation eBills have a dateof accident. This information is critical forinsurance carriers (payers) to nalREF State License(several loops;including 2010AA,2010AB, 2310A,and 2310B)HIPAA situationalRequired when a secondary provideridentification number is necessary to identifythe provider.Workers’ compensationjurisdictionally situationalIn workers’ compensation, most provideridentification loops require the state licensenumber for licensed health care providers onworkers’ compensation transactions.2300 ClaimInformationCLM SegmentCLM11-4HIPAA situationalHIPAA implementation guides require thiscode only when the cause is an automobileaccident.Workers’ compensationsituationalFor workers’ compensation, insurancecarriers have indicated a need to determinejurisdiction in certain situations. For workers’compensation eBills submitted throughAvaility, populate CLM11-4 with theappropriate state Compensation Usage Availity, LLC, all rights reserved. Confidential and proprietary.Page 15 of 17 Updated 1/17/2014Comments/Reason for VarianceFor workers’ compensation eBills, theemployer’s name, federal employeridentification number (FEIN), and addressfields are critical elements for insurancecarriers (payers) to confirm coverage andeligibility. This information also ensures thatan eBill is routed to the appropriate payer forprocessing. Additional employer-relatedinformation helps the payer process theeBill.
Availity Workers’ Compensation Companion sation UsageComments/Reason for Variance837Professional,Institutional2300 ClaimInformation PWKHIPAA situationalWorkers’ compensationsituationalIf there is an attachment you want to submitfor the eBill (prior to receiving the fax coversheet), you may populate the PWK segmentas follows: PWK01 Report type code (see HIPAAimplementation guide for accepted values) PWK02 FX (attachment transmissionmethod) PWK05 AC (attachment control numberqualifier) PWK06 Unique attachment controlnumber. This field supports up to 80characters and accepts the specialcharacters ‘ ’ and ‘-‘.Note: You must wait to receive theattachment fax cover sheet from the eBillagent before submitting the attachment. Thecover sheet will contain a new attachmentcontrol number, which replaces the numberyou submitted in the PWK06.837Professional,Institutional2000B SubscriberHierarchicalSBR SegmentHIPAA situationalWorkers’ compensationrequiredFor workers’ compensation, use one of thefollowing claim filing indicator codes(SBR09): WC workers’ compensation AM automobile medicalNote: Refer to the Availity Workers’Compensation Payers List to determine if aspecific payer accepts automobile medical(Auto Only) eBills. Availity, LLC, all rights reserved. Confidential and proprietary.Page 16 of 17 Updated 1/17/2014
Availity Workers’ Compensation Companion GuideAppendix B – Availity Workers’ Compensation Payers ListThe Availity Workers’ Compensation Payers List contains a list of payers to which you can submitelectronic workers’ compensation claims through Availity. The list includes payer name, payer ID, state(s)for which the payer accepts transactions, and the transactions which the payer processes through Availity.Appendix C – Useful ResourcesThe following states have specific rules governing how workers’ compensation claims are handled. Forstate-specific details on workers’ compensation, see the following sites or documents:›Texas Workers’ Compensation: innesota Workers’ Compensation: http://www.health.state.mn.us/auc/mn837p.pdf http://www.health.state.mn.us/auc/mn837i.pdf Availity, LLC, all rights reserved. Confidential and proprietary.Page 17 of 17 Updated 1/17/2014
› Place the fax cover sheet in front of the attachment documents and send via fax to the number indicated on the cover sheet. Note: The fax number may change, so be sure to fax to the number shown on the cover sheet for the specific claim. › Do not write on the fax cover sheet or otherwise alter it in any way. › Do not place your .
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Claim Research Tool Tip Sheet via Availity Provider Portal Go to availity.com Select Availity Portal Login Enter User ID and Password Select Log in 1) Getting Started 1 Oct. 2019 The Claim Research Tool (CRT) is the recommended method for providers to acquire status on claims processed by Blue Cross
The Availity Portal is a multi-payer site where you can use a single user ID and password to work with TriWest and other participating payers online. Providers will need to register for a free Availity account to access all TriWest information, webinar sessions, "MicroLearning" training videos, quick reference guides, .
believes all information in this document to be correct at the time of writing, this document is intended . The Availity Health Information Network is your one stop on the web for secure . Go to www.availity.com and click REGISTER.
Availity Referral Request Job Aid for Humana Overview The Availity menu provides you with the forms you need to submit referral requests. The payer you select determines the way in which the form displays. In most situations, depending on the payer, each form includes only those fields necessary to request the referral.
migration window? On December 20 and 31, as Availity migrates to 5010, payments will be processed from your payers as usual, but the related 835 transaction acknowledgement may be delayed until January 1, after Availity
Google Authenticator), or an Open Authorization token. This token option is best for users who do not have access to a phone or tablet. REGISTERING YOUR ORGANIZATION Use the Manage My Organization page in Availity Essentials to: Register new Availity organizations View the status of registrations you have submitted
The Portal Admin is the primary user for each Client Axcess portal. The Portal Admin may perform all portal-related functions, create other Portal Users and control access for other Portal Users. The Portal Admin user will be the only user that exists initially when a portal is created.
