EDI Transaction Overview and EFT Set Up

General Overview

All Optima Health Companion Guides, located on the right underneath Related Links, are to be used with the HIPAA-AS Implementation Guide. The HIPAA Implementation guides provide comprehensive information needed to create each ANSI transaction set. The Optima Health Companion Guide is used in conjunction with the HIPAA Implementation Guide; it is intended to clarify issues where the HIPAA Implementation Guide provides options or choices to be made.

The HIPAA Implementation Guide is available from the Washington Publishing Company. 

Important Note - at this time the Washington Publishing Company's website is currently offline and the HIPAA Implementation Guide is not available for download.

Business Use

• Each EDI vendor will have to sign a Trading Partner Agreement, which includes the Network Access Agreement and the Business Associate Agreement.
• Each transaction set will be used to expedite the execution of electronic information, and accelerate the processing and payment of a claim or encounter.
• The 837 transaction may be sent daily, with a disposition report available the next business day. The disposition report replaces the 997 Acknowledgement File.
• The 835 transaction file consists of a separate remittance file (ERA) and a separate electronic funds file (EFT).
• Vendors may elect to receive an EFT/ERA from Optima Health directly, as long as they can receive data files in the HIPAA compliant ANSI 835 format.

EFT Payment Schedule

The following information summarizes Optima Health's general payment schedule. In cases where our offices are closed, such as holidays or extremely severe weather, the scheduled payments will be processed on the next business day. While we can not foresee every circumstance, our professionally trained staff will make every effort to adhere to the following payment schedule:

Weekly Payment Processing schedule:

• Monday - All commercial (fully insured), Medicare and Medicaid
• Tuesday - Optima Behavioral Health and Self-Funded employer groups (refer to note 1)
• Wednesday - Federal employee groups and Self-Funded employer groups (refer to note 1)

Payments processed monthly:

• Provider Capitation and Practice Management payments are processed on or before the 15th of every month.
• All remaining payment types not already listed will be processed on or before the 20th of each month.
• For providers who choose to receive their payments electronically, funds are normally deposited 24 hours after the payments are processed. Associated electronic remittance advice is usually transmitted 24 - 48 hours after payments are processed. All other providers will receive paper checks/remittances through the US postal system (refer to note 2)

Note 1: While claims payments are processed on these days, funds are not released until the payments are funded by their associated employer group. This applies to Self-Funded employer groups only.

Note 2: While Optima Health will make every effort to adhere to the payment schedule, the availability of funds is also dependent on the provider's banking institution

Connecting With Optima Health Using a Web Browser

Use the following address to access the FTP site: https://goanywhere.sentara.com

This option requires the vendor to access the above site using a Web browser (i.e., Google Chrome, Edge, Firefox).

Once the site is accessed, the following will occur:

1) A window to enter the User name and password will display -- see below.

2) After the proper credentials are entered, the Goanywhere FTP portal will display allowing access to the vendor's local source and a remote source (Optima Health site)

Electronic Transaction Questions?

Please contact us.

Testing

Once a Trading Partner Agreement is signed and the method of transferring files determined, test files may be submitted to Optima Health.

• Inbound transactions will be tested with Claredi to ensure transactions are valid and compliant.
• 837 claims must have valid Optima Health member ID numbers and Optima Health provider ID numbers.
• Optima Health will work with all trading partners to identify and eliminate errors.
• The Electronic Funds Transfer/Electronic Remittance Advice implementation timeline is dependent on the trading partners ability to test the receipt and distribution of the EFT/ERA data files.
• Testing is expected to take no more than 2 months to complete.
• Optima Health will notify trading partner that transaction testing is complete and schedule a mutually agreed upon date to move the transaction to production.