The Provider sends an 837 Medical Bill (ASC X12 837 Health Care Claim) to the appropriate MCO for processing.

The MCO performs the first level of adjudication on the 837 Medical Bill. If there is missing or invalid information on the 837 Medical Bill, the MCO rejects the 837 Medical Bill and sends a 277 Rejection Advice (ASC X12 277 Health Care Claim Status Notification) to the Provider. This is an iterative process until the 837 Medical Bill has passed the first level of adjudication.

Once the MCO has successfully completed the first level of adjudication, the MCO sends an 837 Payment Request (ASC X12 837 Health Care Claim) to BWC.

BWC adjudicates the 837 Payment Request and if errors exist, BWC rejects the 837 Payment Request and sends an 824 Payment Rejection (ASC X12 824 Application Advice) to the MCO.

Once BWC has successfully adjudicated the 837 Payment Request, the 835 Remittance Advice (ASC X12 835 Health Care Claim Payment/Advice) and EFT Payment (Electronic Funds Transfer) are sent to the MCO for distribution to the Provider.

Upon receipt of the 835 Remittance Advice and EFT Payment from BWC, the MCO will distribute a Remittance Advice (835 Remittance Advice or Paper Remit) and Payment (EFT or Check) to the Provider.

Additional Technical Notes:

• All EDI transactions should be acknowledged by the ASC X12 997 Functional Acknowledgment
• A Clearinghouse may be utilized for the Provider and MCO transaction processing