EDI Claims Processing

There are different ways to file claims depending on the situation. If the instructions below do not answer your questions, please view our frequently asked questions or contact us.

Preparing Your Management Software for EDI

EDI processing requires a few minor modifications in your software set up. Refer to Preparing Your Management Software for EDI for more information.

Claims Submission Instructions:

For successful EDI processing, you need to complete the CMS-1500 accurately. Please review the CMS-1500 Completion Instructions to be sure you have complied with the EDI and AHC requirements. There are four different types of claims processing you need to understand that affect your AHC claims. Below are instructions for all four types of claims processing.

  1. Instructions for AHC in-network claim submission. If you are not sure which claims should be processed as in-network claims, view the network affiliations. If a payor appears on the network affiliations, then their claims should be filed according to these instructions.

  2. Claims that are not included in the network affilations list may still be filed electronically. Follow these instructions for out-of-network claim submission.

  3. Instructions for the Office Ally Online Entry Tool for providers without claims management software.

  4. Instructions for Paper Claim Submission for when claims cannot be filed electronically. There are occasions when a paper claim is necessary. When a payor is not capable of accepting electronic claims, a payor is not on the Office Ally Payer List, or a payer requires pre-enrollment are all times when paper claims must be filed. Pre-enrollment only requires paper claims during the pre-enrollment process. Payors identified with ***** on the OA Payer List require pre-enrollment. For more information on the pre-enrollment process, refer to our frequently asked questions.

EDI Claims Follow-Up

Refer to EDI Claims Follow-Up for additional information on what you can expect after uploading your claim and additional tools to help you with tracking and correcting your claims online.