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EDI Forms

What are Electronic Claims
Advantages of EDI
Becoming an EDI Trading Partner
Frequently Asked Questions
EDI Forms


The links below are available in the Adobe Acrobat format, and require the Adobe Acrobat Reader 5.0.


EDI Applications & Forms

EDI Applications

BBS EDI Application -- to submit electronic claims through the BBS (Bulletin Board System) via dialup modem

KY Medicaid Trade File Application -- 837/999 & 835/U277 transactions: -- to upload electronic claims in batch form and receive acknowledgement response in Kentucky Healthnet. Electronic remittances and suspended claims are available after each weekly financial cycle is run. This option is for providers only.

KY Medicaid Trade File Application -- 270/271 & 276/277 transactions -- to upload patient eligibility and/or claim status requests in batch form and receive responses in Kentucky Healthnet.This option is for providers only.

KY Medicaid Web Service -- 837/999 & 835/U277 transactions -- to submit electronic claims and receive acknowledgement response in real time. Electronic remittances and suspended claims are available after each weekly financial cycle is run.

KY Medicaid Web Service 270/271 and 276/277 transactions -- to submit electronic patient eligibility and/or claim status requests and receive responses in real time.

EDI Forms

Electronic Media Addendum (MAP 380)

Electronic Media Billing Agency (MAP 246)

Electronic Remittance Advice (ERA 835)

KY Medicaid Administrator Change Request

Paper version (ERA 835)

Pin Release form

Recommended EDI Billing Agency Clearing House Contact List

Recommended EDI Vendor list

EDI Customer Service Survey

Last Updated 8/8/2005 
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