Provider EDI Resources

Providers may use practice management system vendors, billing services or clearinghouses to submit claims and other electronic data interchange (EDI) transactions to Sanford Health Plan. These type of vendors offer a variety of EDI solutions to the health care community and charge fees or transaction costs for their services. Please Note: Sanford Health Plan does not specifically recommend or endorse any vendor or billing service.

Trading Partner Electronic Transaction Exchange Enrollment

In order to exchange data electronically with Sanford Health Plan, Trading Partners must complete our Trading Partner Agreement

The Trading Partner Agreement shall be interpreted to be consistent with the HIPAA requirements on trading partner agreements found at 45 CFR § 162.915.

Resources and Information about EDI:

837 Transactions - Electronic Claims Submission

The 837 transaction set is an electronic version of a Health Care Claim

Sanford Health Plan encourages the use of EDI transactions to increase efficiency and reduce errors. Sanford Health Plan will accept ANSI 837 version 5010 compliant claim transactions meeting our companion guide criteria.

Sanford Health Plan has direct connections with Change Healthcare and several other clearing houses. Claims are to be sent through Clearinghouses with Payor ID 91184.

835 Transactions – Electronic Remittance Advice (ERA)

The 835 EDI document type is an electronic version of a Health Care Claim Payment/Advice.

Sanford Health Plan has partnerships with the Change Healthcare to send 835 transactions. To receive the 835 transactions directly from Sanford Health Plan, complete the Sanford Health Plan 835 Form

Electronic Funds Transfer (EFT)

EFT is the electronic transfer of money from one bank account to another, either within a single financial institution or across multiple institutions, via computer-based systems, without the direct intervention of bank staff.

By enrolling to receive EFTs, Provider experience quicker receipt of payments. To enroll and begin receiving EFT payments from Sanford Health Plan, please complete the Sanford Health Plan EFT Enrollment Form.

Sanford Health Plan also partners with Change Healthcare to deliver ePayment services, consisting of electronic funds transfer (EFT) and electronic remittance advice (ERA) transactions in the postable 835 format. Change Healthcare provides payer remittance data electronically via Change Healthcare Payment Manager, which is offered as a complimentary service with EFT enrollment. You will continue to receive paper remittances for 45 days after EFT enrollment. After the 45 days has expired, paper remittances will no longer be sent. However, these documents will continue to be available electronically through Payment Manager. With Payment Manager, staff can search, view or print each remittance as needed. For enrollment to Change Healthcare ePayment, simply follow the instructions outlined in the following link to begin receiving electronic payments and remittance advices. To enroll with Change Healthcare for EFTs, follow the Change HealthCare EFT instructions.

270/271 Transactions – Eligibility & Benefits Inquiry (Real Time Transactions)

The EDI 270 Health Care Eligibility/Benefit Inquiry transaction set is used to request information from a healthcare insurance plan about a policy’s coverage’s, typically in relation to a particular plan subscriber. The 270 transaction is used for inquiries about what services are covered for particular patients (policy subscribers or their dependents), including required copay or coinsurance.

For more information about 270/271 transactions please contact our EDI department.

276/277 Transactions – Claim Status Requests (Real Time Transactions)

The EDI 276 transaction set is a Health Care Claim Status Inquiry. It is used by healthcare providers to verify the status of a claim submitted previously to a payer. The payer provides the requested information in response to the 276 request using a 277 Claim Status Response transaction.

For more information about 276/277 transactions please contact our EDI department.