|OhioBWC - Provider - Service: (EDI Implementation Guide Downloads) - Business Level|
The Provider sends a Medical Bill to the appropriate MCO for processing. The Medical Bill can be sent to the MCO via the EDI Provider 837 electronic format, a paper bill, or any other mutually agreed upon electronic format.
The MCO performs the first level of adjudication on the Medical Bill. If there is missing or invalid information on the Medical Bill, the MCO rejects the Medical Bill and sends a Rejection Advice to the Provider. This is an iterative process until the Medical Bill has passed the first level of adjudication.
Once the MCO has successfully completed the first level of adjudication, the MCO sends a Payment Request to BWC.
BWC adjudicates the Payment Request and if an error exists, BWC rejects the Payment Request and sends a Payment Rejection to the MCO.
Once BWC has successfully adjudicated the Payment Request, the Remittance Advice and Payment are sent to the MCO for distribution to the Provider.
Upon receipt of the Remittance Advice and Payment from BWC, the MCO will distribute a Remittance Advice and Payment to the Provider.