WPS Health Insurance

Electronic Data Interchange (EDI) Terminology

Listed below are the definitions of several terms and acronyms you may often see and hear when referring to electronic claim submissions:

| A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |

Acronym list

A

Authenticate - Verifying the identity of an entity. Do you have the key?

Authorization - The right to perform the action. Does the key fit?

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B

Business Edits - Editing of data unique to WPS.

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C

Certificate - A digital means by which a user is authenticated.

Clearinghouse (CH) - An external submitter that sends and receives electronically for multiple providers. Also known as a billing agent or any third party agent.

Clearinghouse Agreement - An agreement that ensures the confidentiality, security, and integrity of data being shared by third party agents that represent providers, including NSVs, value-added networks, clearinghouses, and billing agents.
Agents that represent providers, including NSVs, value-added networks, and a classification of billing agents that will send and receive electronic transactions, must sign an agreement.

Connectivity Agreement - An agreement that ensures the confidentiality, security, and integrity of data being shared by Trading Partners/Submitters and Providers including Providers submitting direct as Submitters, third party agents that represent providers, NSVs, value-added networks, clearinghouses, and billing agents. All submitter accounts require a Connectivity Agreement.

Contract - A block of business obtained by division. An agreement between two or more business partners, especially one that is written and enforceable by law. There can be many identifiers to represent a single contract.

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D

Division - One of the portions into which something is regarded as divided and which together constitutes a whole.  WPS Health Solutions identifies it’s divisions as Medicare, TRICARE and WPS.

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E

EDI Provider Agreement - Agreement secured by EDI that authorizes a provider to submit electronically through a specific submitter.  Agreement is unique by division.  An agreement signed by a Provider of service to authorize Provider to electronically exchange any transaction other than an Electronic Remittance Advice.  EDI agreements are required prior to any exchange of data.

Electronic Funds Transfer (EFT) Agreement - An agreement signed by a Provider of service to authorize Provider to electronically receive funds from a WPS Health Solutions Division.  EFT agreements are required in order to initiate Electronic Funds Transfers.

Electronic Remittance Advice (ERA) Agreement - An agreement signed by a Provider of service to authorize Provider to electronically exchange the Electronic Remittance Advice (ERA) (835) transaction.  ERA agreements are required prior to any exchange of remittance data.

External Submitter - Non-WPS entity that sends or receives documents defined by a unique identifier.

External Trading Partner - Non-WPS entity that sends or receives documents defined by a unique identifier.

EZComm Transfer Protocol - An easy-to-use data transfer protocol, which allows secure data exchange over the Internet. It allows trading partners to exchange documents with the WPS host without conforming to a particular business protocol standard.

EZComm - is only used when transmitting Non-X12 exchanges. These exchanges include transactions sent compressed, such as .zip, a PKZip compression.

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I

Inbound Exchanges - From an External User perspective Inbound Exchanges consist of exchange notices sent by WPS Health Solutions to the Trading Partner, such as acknowledgements (TA1,999,277CA) and 835 Electronic Remittance Notices.

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L

Line of Business (LOB) - Individual WPS receiver defined by a unique identifier. There can be many lines of business to represent a single contract.

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N

Network Service Vendor (NSV) - An entity that provides secure connectivity services, but does not have access to content of the data being transmitted.

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O

Outbound Exchanges - From an External User perspective, Outbound Exchanges consist of exchange notices sent by Trading Partners to WPS Health Solutions, such as claim transactions (837), and Eligibility Request and Response transactions (270/271) or Claim Status Request and Response transactions (276/277).

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P

Provider - An entity identified through NPI or Tax ID that performs a service and exchanges electronically via one or more external submitters.  An entity that owns the healthcare data being submitted. It is most likely the provider, hospital, clinic, etc.

Provider Actions:
  • Registers for EDI
  • Registers for ERA
  • Registers for EFT
  • Submitters approved for EDI actions
  • Participation in Contract

Provider Exempt Submitter - A submitter type that does not support a provider. This type of Submitter is not required to have Provider agreements signed in order to transact electronically or test the system.  Provider Exempt Submitters are auto-approved for LOB/TXN enrollment but still have to test transactions.  Examples of Provider Exempt Submitters are Vendors and Third Party Processors.

Provider Exempt Transaction - Transaction that does not require provider agreements. These are transactions that do not have provider involvement. Examples of Provider Exempt transactions would be the 820 and 834.

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S

Submitter - Individual entity that sends or receives transactions defined by a unique identifier.

Super User - Administrator for the Corporation Account/Business in WPS Community Manager.  Initial person that registers the Corporation or Business and will be responsible for management of the account(s).

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T

Third Party Processer (TPP) - An external submitter whose role as a third party entity is to exchange transactions with health plans but doesn’t initiate any contact with the provider.  Third party processors may also price claims as a function of their role As a Provider Exempt Submitter.

Trading Partner - Individual entity that sends or receives transactions defined by a unique identifier.

Trading Partner Corporation - Corporation or Company level entity that has one or more submitter that send or receive transactions electronically defined by a unique identifier.

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V

Validation - A routine to authorize or authenticate a person, place or thing

Vendor - A vendor provides hardware, software and/or ongoing support for total office automation or submission of electronic EDI transactions directly to individual providers, billing agent or clearinghouses/VANs/NSVs.  (Vendors submit for software testing purposes only.) Vendors are considered Provider Exempt. Vendors do not submit Production transactions and are not given Production indicators

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W

WPS Community Manager - Provides current business capability similar to WTPS and WEPS. Allows users to manage their user accounts, enroll for lines of business and transactions, enroll providers to transactions, and create reports of submitter to provider relationships.

WPS Gateway Express (WGE) - TIBCO Product will provide current business capability similar to Secure-EDI Gateway, Medicare EDI Gateway and WGBBS.

WPS Community Manager Display and Reporting Tool - WPS Community Manager Tool that allows Search and Reporting of Submitter relationships to lines of business/transactions and Providers. Allows Submitter to track and manage electronic accounts and relationships. Tool provides similar function as WTPS.

WTPS - WPS Trading Partner System. Tool that manages Submitter and Provider enrollment.  
Will be replaced by WPS Community Manager.

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Acronym Descriptions

API Application Program Interface
CAQH Council for Affordable Quality Healthcare
CH Clearinghouse
CRL Certificate Revocation List
DCN Document Control Number
EDI Electronic Data Interchange
EFT Electronic Funds Transfer
ERA Electronic Remittance Advice
FFM Federally Facilitated Market
HIPAA   Health Insurance Portability and Accountability Act
ICN Internal Control Number
ISA X12 Interchange Header Identifier
LOB Line of Business
MFT Managed File Transfer
NSV Network Service Vendor
TP Trading Partner
TPP Third Party Processor
WGE WPS Gateway Express
WTPS WPS Trading Partner System