Electronic Claim Submission and Electronic Data Interchange
Frequently Asked Questions
Electronic Data Interchange (EDI) is the exchange of information for routine business transactions in a standardized computer format; for example, data interchange between a practitioner (physician, psychologist, social worker) and a payer (Optum). EDI originated as a means of reducing costs through the electronic transmission of business information.
Yes - Optum currently accepts behavioral health and EAP claims electronically. These claims can be submitted electronically through the Claim Entry feature of Provider Express or as an EDI transaction.
Performing claim submission electronically offers distinct benefits:
- It's fast - eliminates mail and paper processing delays
- It's convenient - easy set-up and intuitive process, even for those new to computers
- It's secure - data security is higher than with paper-based claims
- It's efficient - electronic processing helps catch and reduce pre-submission errors, so more claims auto-adjudicate
- It's complete- you get feedback that your claim was received by the payer
- It's cost-efficient - you eliminate mailing costs, the solutions are free or low-cost
Optum strongly advocates the use of electronic transactions between providers and payers for claim submission and other routine interactions. There is no better time than today to start electronic transactions with Optum.
Optum uses two primary sources for electronic transactions from clinicians:*
- Provider Express - the secure section of Provider Express allows network clinicians and group practices to perform claim submission and other transactions electronically, in real-time. This direct data entry solution is free to Optum in-network clinicians and group practices and is designed for 24/7 use. Provider Express availability exceeds 99.8% so it is ready when you are. All you need is a computer with Internet access and a Web browser. To obtain a Provider Express user ID, click the First-time User link on the home page.
- EDI - electronic data interchange (EDI) transactions are conducted through a clearinghouse vendor. EDI is ideal for submitting batches of claims electronically right out of your practice management system software and for tracking responses back from the payer(s). EDI transactions can be configured for either single-payer or multi-payer needs.
EDI services can be set up for both network and out-of-network clinicians and facilities. If you are interested in EDI transactions, Optum can recommend suitable clearinghouse vendors depending on your needs. Please visit Optum Insight at optum.com/edi or email them at firstname.lastname@example.org, and include your name and contact information (telephone and e-mail address), your Tax ID(s) and entity name, approximate number of Optum claims per month, and your interest in either a single or multi-payer solution. We will put you in touch with appropriate vendors to provide you with EDI services. Be advised that some clearinghouse vendors may charge a fee per transaction or per month depending on your needs.
A Payer ID is the assigned code that identifies and directs the electronic (EDI) submission of a claim to the correct payer and claim payment system. The Optum payer ID is 87726.
A payer ID is not necessary to submit behavioral health or EAP claims on Provider Express or via paper.
Clinicians may choose any clearinghouse vendor to submit their claims. The clearinghouse is responsible for getting the claims to Optum.
Yes - simply enter the industry-standard "HJ" modifier (with the relevant CPT code) in the appropriate field of box 24D on the CMS-1500 claim form when filing EAP claims.
*Please note that network clinicians can use both Provider Express and EDI for electronic transactions. You don't need to choose one or the other.
We accept electronic claims and other transactions for members managed by the following companies:
- OptumHealth Behavioral Solutions of CA
- PacifiCare Behavioral Health
Please contact the EDI Support Desk at (800) 842-1109.