EDI Services Testing Procedures

Testing is required for providers and submitters prior to electronically transmitting claim files for payment. Testing requirements are in compliance with the CMS’ Medicare Claims Processing Manual, Publication 100-04, §50.4.1.  There are some exceptions for submitters who are using a software product that has been tested by the vendor for the Medicare type of bill you will be submitting; however, it is recommended that all new submitters voluntarily test to be sure that your software is set up correctly and building the claim files appropriately.

To verify that your software product is “approved”, check the Approved Vendor List. Here, you will be able to view a complete list of approved vendors and their associated software products, version numbers, and TOBs.

Test claims will not be processed for payment. If you use actual claims for testing, you will need to resend them in production once you have completed the testing process and been approved for access to production by an EDI Service Customer Service Representative.

Testing Requirements

Test files must include a minimum of 25 claims. Test files must include claims with all types of bills (TOBs) you will be sending to us for payment.

Skilled Nursing Facilities need to send in both inpatient (21X TOB) and outpatient (23X TOB) claims if you bill for both. Test files must pass 100% standard syntax editing (file layout, record sequencing, balancing, alpha-numeric/numeric/date file conventions, field values, and relational edits).  Reports provided in your FTP mailbox will identify any errors encountered at this level.

Test files must also pass, at a minimum, 95 percent accuracy in data testing for data validation (procedure codes/diagnosis codes/modifiers).  To receive the results of this level of testing, you must contact the EDI Services area.  An EDI representative will check the results of your claims processing in the FISS test system.

Submitting the Test File

It is not necessary to contact EDI Services before sending a test file.  Test files must be named "txxi####.clm".  The "#" is a numerical sequence beginning with zero and incrementing for each consecutive test file.  The "xx" is your state code, such as "al" for Alabama or "ga" for Georgia.  So, for a "ga" submission, the name could be tgai0000.clm.

Note: If you are using Cahaba Health Insurance Portability and Accountability Act (HIPAA) Scripts to facilitate transmission of your electronic files, you must be sure to use “t” (for test) when prompted to indicate “Production (P) or Test (T)” in setting up the INI file. Test files transmitted prior to 3:30 p.m. Central Time (CT), Monday through Friday will process through Level 1 and Level 2 editing on the day of transmission.

Test files transmitted after 3:30 p.m. CT, Monday through Thursday will process through Level 1 and Level 2 editing the next day. Test files transmitted after 3:30 p.m. CT on a Friday will process through Level 1 and Level 2 editing the following Monday.

Note: Test cycles do not run on weekends, the last day of the month, or holidays.

Test Results

Using the information provided above to determine when your file will be processed will help you determine when your “Daily Log” report will be available. Generally, this is available two hours after transmission for files processed the same day as transmission and on the following processing day for all others.

You must download the Daily Log to determine if the claims have passed Level 1 and Level 2 editing. Any errors encountered will be listed. Claims accepted will be processed through Level 3 and Level 4 editing with the next processing cycle and an “Audit Report” will be made available.

You must download the Audit Report and call EDI Services. An EDI Services Customer Service Representative will review your results with you, assist you with any errors on the Audit Report, and provide you with feedback. If your test file meets the accuracy requirements (100 percent syntax, 95 percent data validation) and is accepted into the claims processing system, the EDI Service Customer Service Representative will perform the necessary updates on our system to allow you to submit claims in production for payment.

Assistance

If you need assistance, go to the Electronic Data Interchange section of the Telephone Us page to contact an EDI Services Customer Service Representative.

Page last updated: May 13, 2010

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