Last Updated 12/06/2018
Last Updated 12/06/2018
EDI refers to the structured transmission of data between organizations by electronic means. Organizations that send or receive documents between each other are referred to as "trading partners" in EDI terminology. The trading partners agree on the specific information that is to be transmitted and how it should be used.
How does Senior Whole Health use EDI?
Senior Whole Health uses a clearinghouse to send and receive electronic data for the purpose of adjudicating claims from its healthcare providers.
What is a clearinghouse?
A clearinghouse is a company that provides connectivity and often serves as a "middleman" between physicians and billing entities, payers and other health care partners for the transmission and translation of the claims information into the specific format required by Senior Whole Health to pay the claims. The following demonstrates the process:
- Physician practice
Compiles and sends a batch file using a downloadable form from the clearinghouse
Sorts, formats, and translates a batch file into a standard format
Submits claims to exclusive payer clearinghouse
- Payer exclusive clearinghouse
Translates the claim into payer format
Senior Whole Health receives EDI files through Change Healthcare.
What are the Benefits?
There are many benefits to sending your claims electronically to Senior Whole Health, including:
- Decreased data entry errors... Faster payment.
- Reduced paper claim costs... No paper claims to print.
- Lower printer costs... No ribbon or toner expense.
- Reduced mailing costs... No envelopes or stamps to buy.
- Decreased office costs... No overhead to print, sort, stuff, and mail claims.
- Increased staff efficiency... Quicker claims turnaround time.
EDI claims information is supported in two formats:
- UB-04 & UB-92 (CMS-1450) – Support Institutional Claims: Hospitals & Skilled Nurses
- CMS 1500 – Support Professional Claims: Medical Services & Health Plans
Senior Whole Health accepts the following Health Insurance Portability and Accountability Act (HIPAA) compliant claim transaction types:
- 837P - Professional Claims Submission
- 837I - Institutional Claims Submission
The 837 file format is an efficient and direct solution for billing your claims. This transaction type can be used to submit health care claim billing information, encounter information, or both, from providers to payers either directly, or via intermediary billers or for Senior Whole Health through a claim clearinghouse.
Senior Whole Health will provide a paper Remittance Advice with your claims payment.
How to get started using EDI
ON24/7 is a web-based system that allows Change Healthcare customers to submit service requests and check on the status of those requests 24 hours a day, 7 days a week. Please contact Change Healthcare directly at 1-888-363-3361 or visit the ON24/7 site.
Note: Senior Whole Health Payer ID is 83035.
How long will it take before payment is received?
Senior Whole Health processes EDI files on a daily basis. Therefore, you can generally expect payment within 10-21 calendar days of our received date. If you believe that Senior Whole Health has not processed your file within 30 calendar days of our expected received date, or you have questions about your remittance advice, please contact Senior Whole Health's Claims Department at 1-866-233-4773.
What if I need to submit supporting documentation, or a corrected claim?
In the rare case that this is necessary, please submit your corrected claim on paper with the supporting documentation to:
Senior Whole Health
PO BOX 956
ELK GROVE VILLAGE, IL 60009-0956
Last Updated 02/21/2018
We Help You to Help Your Patients.
Information Regarding Coronavirus (COVID-19)
Provider Correspondence 3/24/20: SWH will implement the following policy from March 23 - June 23, 2020 (PDF)
Provider Correspondence 3/23/20: Please share this with your admissions department, or whomever conducts Prior Authorization reviews at your facility (PDF)
Provider Correspondence 3/16/20: Clarity around coverage and clinical issues related to COVID-19 (PDF)
Provider Correspondence 3/16/20: A message from MassHealth (PDF)
Model of Care Training
The Centers for Medicare & Medicaid Services (CMS) requires Special Needs Plans (SNPs) to provide initial and annual Model of Care (MOC) training to our network providers and all out-of-network providers seen by our members routinely. This training ensures providers have knowledge of the Senior Whole Health population and our Model of Care.
Senior Whole Health Model of Care (PDF)
Please complete the 2020 training by October 31, 2020. Click here to complete.
COVID-19 Provider Webinars: Please click here to view information & materials for past as well as upcoming Provider webinars.
How to build resilience and adaptive skills during the pandemic Tips for caring for the emotional health and wellness of you and your family during these uncertain times. Learn more. If you missed the live webinar, the recording is posted here.
Senior Whole Health now offers Electronic Remittance (ERA) and Electronic Fund Transfer (EFT). If you are currently enrolled with Change Healthcare ERA or EFT you should be seeing your payments electronically. If you are not enrolled, you can switch from paper to electronic payments over the phone, online, through the mail or via fax.
Senior Whole Health is dedicated to providing our members with the best care possible and keeping them healthy and independent.
Senior Whole Health Nurse Care Managers are assigned to each member. These nurses help plan, organize and arrange services to effectively coordinate medical, behavioral, pharmaceutical, and social and community based services with the providers, local elder services agency and others involved in our members' care. Senior Whole Health Nurse Care Managers are available by phone 24/7 to both our providers and members in order to best facilitate treatment.
The result is a comprehensive, team-based care plan that anticipates and adapts to the changing needs of each member, striving to keep them secure, independent and living in the comfort of their own home.
Click here to view the Senior Whole Health Provider Manual (PDF).
Senior Whole Health's Dental Provider Manual is available through SKYGEN USA’s Provider Portal.
Click here to view Senior Whole Health's HEDIS® Measures of Focus (2020) (PDF).
Click here to view Senior Whole Health's HEDIS® Tips for Quality Care (PDF).
Enroll in Medicare as a Provider Now! Learn more.
Visit the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to securely and electronically submit and manage Medicare enrollment information.
First Tier, Downstream, and Related Entities (FDR) Compliance Guide & Attestation: Click here to review and complete the FDR Annual Compliance Attestation
Click here to view information about False Claims Act laws.Senior Whole Health encourages you to report fraud or suspected fraud by calling the SWH Fraud Hotline at 1-800-341-4915, our anonymous compliance hotline at 1-800-915-2108 or the Main SIU Hotline at 1-800-755-0850.
Click here to view Senior Whole Health's Fraud Waste and Abuse Policy.
Approved requests will be processed by Senior Whole Health credentialing specialists, who may contact you to obtain additional information required to complete your application. If you are a solo practitioner or part of a non-participating group, you will be required to sign a Senior Whole Health Provider Agreement. If applicable, a Provider Agreement will be mailed to you.
Please note that Senior Whole Health cannot guarantee that providers requesting to be credentialed shall become contracted providers. Providers are subject to reviews based upon network adequacy and Senior Whole Health qualification standards.
Credentialing is finalized upon approval from the Medical Advisory Committee and by the return of a countersigned Agreement (if applicable) and accompanying letter noting that you have been credentialed as a Senior Whole Health provider.
Last Updated 01/24/2019