Interoperability and Electronic Data Interchange

EDI is a controlled transmission of claims data between providers and CalOptima Health. When using EDI, it takes significantly less time for provider offices to process claim submissions. This reduces payment cycle times.

Benefits of using EDI:

• Increases productivity without increasing staff
• Eliminates printing claims, cost of mailing and mail supplies
• Once set up, providers can send claims to all payers
• Correctly entered, claims will auto-adjudicate and will not require manual work
• EDI is the most efficient way to process claims and receive payments

Eligibility/Benefit Inquiry 270

To inquire about the health care eligibility and benefits associated with a CalOptima Health member.

The 270 typically includes:

• Details of the sender of the inquiry (name and contact information of the information receiver)
• Name of the recipient of the inquiry (the information source)
• Details of the CalOptima Health member, related to the inquiry
• Description of eligibility or benefit information requested

Use the 270 transaction with the EDI 271 transaction. The 271 is the Health Care Eligibility/Benefit Response used to transmit the information requested in a 270.

Eligibility/Benefit Response 271

CalOptima Health sends the 271 transaction in response to the 270 inquiry. The intention is not to provide a complete representation of all benefits, but rather to address the status of eligibility, benefit information and member financial responsibility, when applicable.

The 271 typically includes:

• Details of the sender of the inquiry (name and contact information of the information receiver)
• Name of the recipient of the inquiry (the information source)
• Details of the CalOptima Health member, related to the inquiry
• Description of eligibility or benefit information requested

The 271 response should not be interpreted as a guarantee of payment. Payment of benefits remains subject to all health plan benefit terms, limits, conditions, exclusions and the member’s eligibility at the time the provider renders services.

What are the benefits?

Electronic eligibility verification may have these benefits:

• Reduced collection and billing costs
• Decreased bad debt
• Improved cash flow
• Increased productivity and efficiency
• Fewer rejected claims
• Less time spent on manual, administrative tasks
• Expedited reimbursement

Providers can perform eligibility (270/271) transactions in real-time mode, based on connectivity method.

Health Care Claim Status Inquiry 276

For health care service providers to inquire about the status of a claim or claims submitted to CalOptima Health for payment consideration, either on paper or electronically. 

HIPAA specifies the 276 transaction for the electronic submission of claim status requests. The transaction typically includes:

• Provider identification
• Member identification
• Member information
• Date(s) of service(s)
• Charges

Submitting a 276 status request to CalOptima Health is your first step in the claim status request/response process. CalOptima Health provides the response to the requested information using a 277 claims status response transaction.

Health Care Claim Status Response 277

CalOptima Health uses this to respond to a health care service provider’s inquiry about the status of a claim or claims submitted to CalOptima Health, either on paper or electronically, for payment consideration.

The 277 transaction, specified by HIPAA for the submission of claim status information, can be used in one of the following three ways:

• A 277 transaction may be sent in response to a previously received 276 claim inquiry
• CalOptima Health may use a 277 to request additional information about a submitted claim (without a 276)
• CalOptima Health may provide claim status information to a health care service provider using the 277, without receiving a 276

Information provided in a 277 transaction generally indicates where the claim is in process, either as pending or finalized. If finalized, the transaction will indicate the disposition of the claim: rejected, denied, approved for payment or paid.

The 277 may also indicate the claim approval or paid status as well as payment information, such as method, date, amount, etc. If denied or rejected, the transaction may include an explanation, such as if the patient is not eligible.

What are the benefits?

Electronic claim status transactions may have these benefits:

• Increased productivity and efficiency
• Less time spent on manual, administrative tasks
• Decreased duplicate claim submissions

CalOptima Health will acknowledge receipt of all electronic claims within two working days, and paper claims within 15 working days. Providers should not interpret the acknowledgment of a claim as a guarantee of payment. Payment of benefits remains subject to all health plan benefit terms, limits, conditions, exclusions and the member’s eligibility at the time the provider renders services.

Providers can perform claim status 276 and 277 transactions in real-time mode, based on connectivity method.

Getting Started

For an overview of how this process works and the user agreements that may be required prior to activation, visit the Office Ally website for eligibility/benefit requests.

If you have questions about real-time transactions, contact the Office Ally Customer Service department at 360-975-7000.

Other Resources

As a provider, you may call the CalOptima Health Claims department at 714-246-8885 to verify member claim status.