Electronic Data Interchange (EDI)
All documents are in pdf format
- RI Medicaid HIPAA 5010
- Trading Partner Enrollment
- MMIS Claim Type to HIPAA Crosswalk
- Claim Status Response - Explanation of Benefits
- Adjustment Reason Code - Explanation of Benefits
- Provider Electronic Solutions Software (PES)
- Provider 277 Crosswalk to EOB/ESC
EDI questions can be directed to:
Phone: (401) 784-8100 for local and long distance calls or (800) 964-6211 for in-state toll calls
Email: RI EDI Services
For Healthcare Portal password resets, be sure to include your NPI and Trading Partner ID.
Electronic Secondary Billing for Medicare and Senior Replacement Plans
Please view billing instructions if using the Provider Electronic Solutions Software. The appropriate Carrier Codes can be found in the table below.
Electronic Secondary Billing for Medicare and Senior Replacement Plans
To facilitate electronic billing and proper reimbursement for Medicare and Commercial Medicare Plans (Advantage/Replacement Plans) such as United Senior Care, Blue-Chip Medicare HMO, WellCare Advantage Plan the following fields are required:
- Loop 2320 Other Subscriber Information SBR09 - Must contain MA or MB as appropriate for the claim filing indictor
- Loop 2320 Claim Level Adjustments CAS segment - Must contain Deductible PR 1 or Coinsurance of PR 2
- Loop 2320 Coordination of Benefits (COB) Payer Paid Amount – Must contain the Amount Paid (other insurance paid amount)
- Loop 2330B Other Payer Name (Carrier Code) Segment NM109 Other Payer Primary Identifier – Must contain the appropriate carrier code, see below for a list:
|
MDA/MDB – Medicare |
22A – Aetna Medicare Advantage Plan |
|
06A – United Senior Care |
24A – Connecticare Medicare Advantage Plan |
|
08A – Healthfirst Medicare Advantage Plan |
26A – Humana Medicare Advantage Plan |
|
09A – HMO Blue of Massachusetts Advantage Plan |
26B – Humana Medicare Advantage Dental Plan |
|
12A – Blue Chip Medicare HMO |
89A – Tufts Health Plan (PPO) Medicare Advantage Plan |
|
18A – Wellcare Medicare Advantage Plan |
C01 – CarePlus Advantage Plan |
|
19A – MMM Healthcare of Puerto Rico Advantage Plan |
C02 – Commonwealth Care Alliance, Inc. Medicare Advantage Plan |