Medicare_Carriers_Manual / 3023 / 3023.4_EDI_Testing_and_Verification.--

Why This Topic Matters

It helps organizations understand the Medicare expectations for testing readiness, transaction validation, verification activities, and attachment integrity before and during production electronic billing.

Article Sections

1. A. Testing

   General requirements for EDI trading partner testing and the responsibilities associated with pretesting and active testing. Includes information carriers are expected to provide to submitters and vendors.

2. 1. Pretesting

   Materials and operational information that should be made available before testing begins. Covers communication, process expectations, transaction support, and format-related readiness topics.

3. 2. Testing

   Initial testing expectations and related testing scenarios for new users and existing submitters. Also addresses testing impacts from system, software, and carrier-initiated changes.

4. a. Initial Testing

   Requirements for the first round of transaction testing and review of file format and data quality. Discusses turnaround, thresholds, and the treatment of testing outcomes.

5. b. Automatic EDI Approval

   Situations in which additional testing may not be required for certain new providers or format changes. Describes the general conditions used to evaluate whether testing can be bypassed.

6. c. Testing for Changes Initiated by HCFA or the Carrier

   Testing considerations when Medicare-related system or format changes are introduced. Covers notification, documentation availability, and migration of existing clients.

7. d. Testing for Changes in Provider's System or Vendor's Software

   How provider, vendor, clearinghouse, and network changes may affect testing needs. Explains coordination around evaluating whether retesting is needed.

8. B. Verification

   On-site verification activities for physicians and suppliers after initial electronic claims submission. Focuses on scheduling, sampling, review, reporting, and corrective action.

9. C. Continuing Claim Verification

   Ongoing sampling of provider documentation to confirm that automated bills continue to align with source records. Includes the option for alternative methods when on-site review is impractical.

10. D. Certificates of Medical Necessity (CMNs) and Other Attachments

    Guidance on electronic attachments and the relationship between paper and electronic versions. Also addresses verification of automated attachments and source documentation.

11. 1. Paper vs. EMC

    General direction concerning the creation of paper attachments when electronic versions exist or are available. Addresses attachment format availability at a broad level.

12. 2. Verification of CMNs and Other Electronic Attachments

    Verification expectations for automated attachments and source records, including certification record information used in the process. Focuses on attachment association and documentation integrity.

13. E. Additional Visits to EMC Billers

    Circumstances under which additional site visits may be requested or initiated for electronic billers. Includes handling of potential noncompliance and coordination with the Regional Office.