Electronic Data Interchange

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

• Changes for all trading partners
• Managed care changes
• Replacement MMIS testing

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. At go-live, the 271 response will not contain benefit package, copayment, or plan-specific enrollment information. If a client has any third-party resources (TPR), the 271 will indicate that TPR exists, but not what the specific resources are. You will need to make sure that you obtain these pieces of information through the Web portal or AVR.
• 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 is now focusing on testing for current trading partners in the replacement MMIS. For more information, and links to the Companion Guides for the new system, go to the EDI Registration and Testing page.
 

DHS will hold any new trading partner agreements received on or after June 30, 2008, for registration and testing in December, when the replacement MMIS is fully operational.