Electronic Data Interchange

This page provides information on the changes to electronic data interchange (EDI) in the replacement MMIS.

• Changes for all trading partners
• Managed care changes
• Replacement MMIS testing
• HIPAA Companion Guides for the replacement MMIS

For information on the changes for all fee-for-service providers, go to the Fee-for-service information section of the MMIS Provider Resources site.

For information on the benefits and changes for pharmacy providers, go to the Pharmacy benefit management section of the site.

For information on changes for managed care organizations, go to the Managed care information section of the site.

If you have questions about EDI in the replacement MMIS, contact DHS EDI Support Services at 888-690-9888 or e-mail dhs.edisupport@state.or.us.

Changes for all trading partners

Transaction-specific changes include:

• Dental/Professional Claims Process (837D/P) - EDI submitters will be able to submit up to 50 detail lines, submit dollar amounts up to $9,999,999.99 per detail line and $99,999,999.99 per total claim payment amount, and perform batch adjustments as the 837D and 837P formats allow.
• Institutional Claims Process (837I) - EDI submitters will be able to submit up to 999 detail lines, submit dollar amounts up to $9,999,999.99 per detail line and $99,999,999.99 per total claim payment amount, and perform batch adjustments as the 837I format allows.
• Eligibility Benefits Inquiry (270/271) - The current system processes the 270 batch files overnight. The replacement MMIS will process them as they come in, giving more timely eligibility information. The replacement system will also process incoming 270 transactions submitted through value-added networks (VANs) in addition to the current SFTP process.
• Claims Status Inquiry (276/277) – The current system processes the 276 batch files overnight. The replacement MMIS will process them as they come in, giving more timely information. The replacement system will also process real-time inquiries submitted through both VANs and SFTP.

In addition, the replacement MMIS will support the Prior Authorization Request and Response (278) transaction for Oregon DHS trading partners for the first time.

DHS will require all trading partners to complete re-testing to ensure accurate and timely processing of EDI transactions in the replacement MMIS (see below for more information).

Managed care changes

The replacement MMIS will use the NCPDP pharmacy transaction format for MCO pharmacy encounter submissions. Transaction-specific benefits include:

• Enrollment file (834) – The current weekly file will change to a daily file, providing more timely information.
• Capitation payments (830) –  No significant changes.
• NCPDP pharmacy encounters – Some changes will occur, including how to use processor control numbers on these transactions.

Replacement MMIS testing

DHS will only continue exchanging EDI transactions with trading partners who test to make sure they can submit and receive the updated transactions. This includes submitting 837 claim transactions, 270/271 eligibility verification transactions, 276/277 claims inquiry and response transactions, and using the new 278 EDI transaction for prior authorization (PA).

DHS began EDI testing in the replacement MMIS on July 10, 2008. To make sure all trading partners who exchange data with DHS today can do so in the new system, DHS must complete all testing by Friday, August 29. To meet this deadline, EDI Support Services will test 837 claims transactions for fee-for-service (FFS) providers in priority order:

1. FFS providers billed through clearinghouses first;
2. Managed care organizations second;
3. All other provider submitters (who bill DHS directly) last.

Current trading partners who want to change their add or remove registered EDI transactions or change their submitter information must complete the Exhibit C - EDI Registration Change form (Word) (PDF) no later than 3 weeks before the replacement MMIS goes live. This gives DHS time to test new transactions and new submitters for current TPs before the go-live date.

• Before current trading partners can test their transactions in the replacement system, they must make sure they can connect to the new MMIS server. Make sure to contact DHS EDI Support Services for your current password to the new server. Detailed instructions are available here.

HIPAA Companion Guides for the replacement MMIS (pdf)

These guides will provide you with information about the technical changes to each transaction that you will need to successfully continue EDI transactions with DHS in the replacement system.

• Until the replacement MMIS goes live, these guides are ONLY for submitting transactions with DHS as part of business-to-business (B2B) testing for the replacement MMIS.
• For production transactions (e.g., “live” claims) in the current MMIS, continue to use the main HIPAA Companion Guides and manuals page.