Electronic Data Interchange (EDI) - Point32Health Provider

Sending electronic transactions has a host of benefits — fewer errors, more control over data accuracy, improved cash flow, and lower operating costs. Conduct a broad range of services electronically, including:

Eligibility (270/271 transactions)
Verify patient eligibility, determine copayment at the time of service, and prevent inaccurate patient eligibility information — the #1 reason for EDI claim rejection.

Claims submission (837)

Submit one electronic file for all your HIPAA-compliant professional (837P) and institutional (837I) claims and receive a reply within 24 hours. We accept EDI claims from all major clearinghouses.

Claims status (276/277)

Get information about the status of your claims quickly. Submit 276 transactions to request the current status of a claim or claims, and receive a 277 response to that inquiry.

Referral/notification/authorization (278)
Send and receive referrals in minutes, submit authorization requests and receive instant confirmation of receipt, verify that services are authorized, and support care coordination by ensuring specialists are aware of scope of services/number of visits recommended by PCP.

Remittance Advice (835)
Manage accounts receivable with state-of-the-art reporting. The 835 ERA (Electronic Remittance Advice) reports final claim adjudication results to allow the provider system to auto post claim adjudication.

Connecting electronically: trading partner or direct

Submit electronic transactions directly to Point32Health through a preferred e-channel or indirectly through an intermediary, such as a trading partner or clearinghouse. We have established connections with all major clearinghouses, including NEHEN, NEHENNet, and others.

For direct submission, a provider’s billing system is set up to connect with the Point32Health claims system. there are no charges for direct submission, and the EDI teams listed below can assist with direct set up.

To get started with EDI submission, please contact the EDI team noted below:

Harvard Pilgrim Health Care: [email protected]
Tufts Health Plan: [email protected]

Harvard Pilgrim Health Care EDI resources

EDI set up information Companion guides

The Companion Guides below will assist those responsible for testing and setup of electronic claims-related transactions. Specifically, the guides clarify when conditional data elements and segments must be used and identify codes and data elements that do not apply to Harvard Pilgrim. The Companion Guides supplement the HIPAA Standard Implementation Guides that are available at www.wpc-edi.com/.

In order to simplify transaction information for providers, payers of New England Healthcare EDI Network (NEHEN) collaborated to produce combined 837 Companion Guides. These guides, which are supported by Harvard Pilgrim Health Care and other health plans, can be found on the NEHEN Web site at www.nehen.org and via the links below.

Preferred Channels

E-Transactions Preferred Channels

If Point32Health does not currently have a connection with your preferred trading partner, please direct the trading partner to contact Point32Health to establish a connection.