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Submitting Electronic Claims

 

Register to securely submit electronic claims to Wellmark:

What Happens After You Submit a Claim?

Once you submit a claim to Wellmark:

  • Wellmark examines claims for errors that will stop or delay the adjudication of claims.
  • Wellmark produces two reports containing details about claims that were either accepted or rejected by Wellmark. The TXN (Transaction Summary) report, which includes HIPAA and eligibility verification information, is available within four hours of submission and the Z16 (Wellmark Acceptance) report with specific Wellmark editing information is available the next business date. Please note, the ACA compliant plans (those ID numbers with a W after the three letter prefix, e.g. XQGW00000000) will not be reported back on the Z16 report at this time.
  • Once claims show as 'accepted' on the Z16 report, the claim status can be checked using the Check a Claim tool on Wellmark.com

Testing with Wellmark

 

Wellmark’s test environment may be used to test connectivity as well as your readiness to submit electronic claims and receive electronic remittances. There may be times when testing for new industry adaptations such as new versions of electronic claims (837 transactions) and electronic remittance (835 transactions) is necessary as well. 


Once you have registered for Electronic Transactions, you will be assigned a Web Bulletin Board System (BBS) username/ID and password to submit claims electronically to both Wellmark’s test and production environments.  Your username/ID will not expire; however, your production and test passwords will expire every 30 days. Contact EC Solutions at 800-407-0267 if you need to reset your passwords or have issues with your username/ID.


Requirements for Testing Claims Electronically 

  • Submit your test claim file with the test indicator ‘T’ in the Interchange Control Header Segment (ISA) data element 15.
    Example:  ISA*00*……….*01*SECRET….*ZZ*SUBMITTERID.…*ZZ*RECEIVERSID.…*150101*1253*^*00501*0012345*1*T*:~
  • Valid Wellmark member information must be used on all test claims; this includes the Wellmark ID, patient name, date of birth, and patient gender, etc. 
  • Valid Provider information (NPI and EIN/TIN) must be used on all test claims.
  • The first six characters of the patient account number (loop 2300 CLM01) must always begin with ‘PVTEST’ (all upper case letters). This allows Wellmark to differentiate your test claims from internal testing and ensures you receive the 835 transactions created for the claims you submit. You may include up to 12 additional characters following ‘PVTEST’ for your own reference if necessary. Please note, test 835 transactions will not be delivered to your Test Web BBS mailbox if ‘PVTEST’ is not included in the first 6 positions of the patient account number for each test claim submitted.
    Example: CLM*PVTEST_123456789ab*$$$$$***11:B:1*Y*A*Y*I*P~

Additional Information Regarding Testing 

  • The results received in the Wellmark test environment may be different than what you are accustomed to receiving for production claims. Some of the logic in the test environment may not be ready for provider testing or not yet loaded to production.  
  • Wellmark testers must use valid provider data and valid member data for internal testing. Claims used for internal testing may or may not match claims  you previously submitted to Wellmark's production environment.
  • There may be situations where claims are on the test 835 transactions that were not submitted by you in the test environment. These claims will not have a patient account number beginning with ‘PVTEST’ in the CLP01 segment and should be disregarded when analyzing your test results. 
    • This may occur when the provider and Wellmark testers submit claims to the test environment at the same time of which finalize on the same day. In order to ensure the testing environment operates as closely to production as possible, the claims may be presented on the same 835 transaction.  
  • When it is necessary to test industry adaptations (e.g. ICD-10), Wellmark.com will be the main source for testing information. 



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