Billing Claims Through TriZetto (Gateway EDI)

Before you can use TriZetto to bill claims, you must complete the setup tasks and send a test batch. For instructions, see Getting Started with TriZetto

For information on using the TriZetto eligibility integration in Front Office, see Adding Eligibilities Using the TriZetto Integration.

Submitting Claims Through TriZetto

  1. Open Claims Management.
  2. Click Billing Claims and select EDI Transmission.
  3. From the Carrier drop-down list, select the insurance carriers you want to bill.

    Only carriers with the Electronic Claim Submission check box selected in Administration are available in the list. All carriers are selected by default.

  4. Select a specific Provider, if necessary. All providers are selected by default.
  5. In the Service Date From and Service Date To text boxes, enter or select the date range.

    To search for all claims for the carrier, leave the date text boxes blank.

  6. Click Search.

    All claims with the Ready to Bill status that meet your search criteria appear. If a claim that you want to bill is not listed, check to make sure it is in Ready to Bill status. For more information, go to Setting the Claim Status to Ready to Bill.

    The Provider column in the list includes the originating office for each claim.
  7. Select the check box next to each claim you want to bill.

    To select all claims on the current page of the grid, select the check box in the heading row.

  8. To preview the ANSI 5010 file for the selected claims before submitting the claims to TriZetto, click Create EDI File.
  9. To submit all of the displayed claims to TriZetto, click Create And Send.

    The claim status of each claim changes to Billed, and the claims are sent to TriZetto. To view TriZetto’s status of the claims, go to the TriZetto website. If you need assistance with TriZetto's website, contact TriZetto customer support.

    Resubmitting Failed or Rejected TriZetto Claims

    1. Locate the rejected claim. See Searching for Claims.
    2. Set the claim status to On Hold. See Putting Claims on Hold.
    3. Edit the claim to correct the error. See Editing Claims.
    4. Change the claim status to Ready to Bill. See Setting the Claim Status to Ready to Bill.
    5. If you have more than one rejected claim, repeat steps 1-4 for each.
    6. Once all errors have been corrected, resubmit the claim(s). See Billing Claims Through TriZetto (Gateway EDI).