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Types of EDI Transactions

Electronic Data Interchange (EDI) functionality is utilized by Molina to complete several types of ASC X12N Version 5010 transactions, including:

• Claims Submission (837 Professional and Institutional Healthcare Claims)
• Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) – (835 Healthcare Claim Payment/Advice)
• Referral Certification and Authorization (278 Healthcare Services Review - Request for Review and Response)
• Eligibility for a Health Plan (270/271 Healthcare Eligibility Benefit Inquiry and Response)
• Claims Status (276/277 Healthcare Claim Status Request and Response)

*Ohio Medicaid Providers:  Effective Feb. 1, 2023, EDI transactions (excluding prior authorization requests) must be directed through the Ohio Department of Medicaid Fiscal Intermediary, OMES. EDI transactions submitted directly to Molina will be rejected for the Ohio Medicaid line of business. Please refer to Trading Partners | Medicaid (ohio.gov) for complete EDI reference materials and resources. Note: At a later date, specified by ODM, EDI prior authorizations will also be submitted via OMES.

If a provider is not for 835s with ODM please visit this website to sign up: Required Forms & Technical Letters | Medicaid (ohio.gov). The ODM enrollment will provide ERAs from all payers in the Next Generation Medicaid program.

EDI Claims Submission

The easiest way to submit EDI claims to Molina Healthcare is through a Clearinghouse. You may submit the EDI claims through your own clearinghouse or use Molina’s contracted clearinghouse (see the Clearinghouse Information link for Payer ID information). If you do not have a Clearinghouse, Molina offers additional electronic claims submissions options. Log on to the Provider Portal for additional information about claims submission options available to you.

270/271 Healthcare Eligibility Benefit Inquiry and Response & 276/277 Healthcare Claim Status Request and Response

Molina does not directly exchange 270/271 and 276/277 transactions. The 270/271 and 276/277 transactions are handled by Molina’s contracted clearinghouse Change Healthcare. The transactions may be sent directly to Change Healthcare or via your own clearinghouse. *New York Providers will continue to submit transactions through Claimsnet.

EDI Forms

278 Referral Certification and Authorization Form

The 278 Request transaction is utilized to verify medical necessity for health care services; therefore, additional supporting documentation may be necessary for approval of requested services.