EDI Report Glossary

This glossary includes definitions and examples of several important EDI Reports. As always, feel free to contact PCC Support at 1-800-722-1082 if you have any questions or need help understanding EDI reports.

PCC Reports

preptags/tagsplit Bad Claim Report

This report warns of basic errors and lists claims that could not be approved for electronic submission. It prints out immediately after preptags finishes and is logged in the ecsreports program. Because it includes a list of claims that can not be submitted due to errors, you should review this report every time you run your claims.

Bad Claim Report                        Generated On: March 11, 2005


Date: 03/10/05  PCC #: 243      Patient: Pebbles Flinstone
        Guar PCC#: 751          Cus PCC#: 751    
        Claim is for an insurance company no longer on the account            
        Charge filed with: Cigna $0

In the example above, a claim was rejected because the insurance company (Cigna $0) was no longer listed on the account. The insurance information was probably updated by another user, and the claim probably needs to be pended and re-batched in oops. It may already have been re-batched, but you should review the account to be certain.

Other common errors on this report include missing birth dates and bad addresses.

ECS Batch Log

This is a log, sorted by insurance batch and patient name, of all the claims sent out on a certain date. The ECS program prints this report when it finishes and logs the report in ecsreports. This log is a good starting point for proof of timely filing, though another report may provide more detail.

Run date: 20050310
Batch: PCC - Aetna Claims           

03/08/05 * $ 111.00   - Flinstone, Pebbles
03/08/05 * $ 165.00   - Doe, Johnny
03/07/05 * $ 111.00   - Crusher, Wesley
03/08/05 * $  81.00   - Duck, Louie

Total claims processed: 4
Total claim charges: $468.00          

The report excerpt above shows four claims that were sent out in the Aetna insurance batch on 3/10/05.

PCC Daily Submission Summary

This is a record showing that PCC has received your claims and sent them on to the clearing-house or payor. You should receive this log within 48 hours of running ECS and it is stored in ecsreports. This report is a useful guarantee that your connection to PCC was active and provides a "paper trail" proving that each claim passed through PCC's computer system.

PCC CLEARINGHOUSE
DAILY SUBMISSION SUMMARY
FILE PROCESSING DATE: 03/11/2005
*******************************************************************************
030501021  BEDROCK PEDIATRIC PRACTICE      CLAIM BILLING DATE: 03/10/2005
*******************************************************************************
  PATIENT / CLAIM           PATIENT NAME             CLAIM        
     ID NUMBER          LAST            FIRST   MI FROM DATE     CHARGES
 ***************** ****************** ********** * **********    ********
AETNA HMO 15                       PAYOR ID: 60054
 243 10077         FLINTSTONE         PEBBLES      03/08/2005      111.00
AETNA EPO 10                       PAYOR ID: 60054
 394 10078         DOE                JOHNNY       03/08/2005      165.00
AETNA PPO 8                        PAYOR ID: 60054
 848 10079         CRUSHER            WESLEY       03/07/2005      111.00
AETNA POS 20                       PAYOR ID: 60054
 1068 10080        DUCK               LOUIE        03/08/2005       81.00

030501021   TOTAL                 CLAIMS:      4    CHARGES:       468.00

The above section shows that PCC received and processed four Aetna claims On March 10, 2005.

Capario (ProxyMed, MedAvant) Reports

Capario (ProxyMed) Daily Verification Report

This report is Capario's acknowledgement that they have received your claims, as well as a list of claim problems and rejections. You should receive this log within 96 hours of running ECS and it is stored in ecsreports. Since this report contains a listing of claims that Capario will not be able to send to the payor, you should review this report every time you receive it.

Use the Patient and Claim ID Numbers. Capario reports include the claim and patient ID numbers. You can use that information when searching for information in other reports or in programs like notjane, oops, and pip.

================================================================================
 CAPARIO Daily Verification Report      Date Printed:  3/11/2005      Page   1

 The following claims were REJECTED by Capario.

   PATIENT/            PATIENT           PATIENT      SERVICE     CLAIM   PAYOR
   CLAIM ID           LAST NAME         FIRST NAME      DATE     CHARGES   ID
================================================================================

243 10077             FLINSTONE          PEBBLES      20050308    111.00  60054
  CLAIM PROCESSING DATE: 20050311
  CAPARIO TRACE #: 000000000000001 VAN: 243 10077       PAYOR:
  MESSAGES: REJECTED AT Capario DIAGNOSIS CODE-3 MISSING/INVALID/DUPLICATE
            (60054) (7746)

--------------------------------------------------------------------------------
TOTAL CLAIMS REJECTED BY CAPARIO: 1                    CHARGES:   111.00

==============================================================================
 CAPARIO Daily Verification Report      Date Printed:  3/11/2005      Page   2

 The following claims were ACCEPTED by CAPARIO.

   PATIENT/            PATIENT           PATIENT      SERVICE     CLAIM   PAYOR
   CLAIM ID           LAST NAME         FIRST NAME      DATE     CHARGES   ID
================================================================================

394 10078             DOE                JOHN         20050308    165.00  60054
  CLAIM PROCESSING DATE: 20050311
  CAPARIO TRACE #: 000000000000002 VAN: 394 10078       PAYOR:
  MESSAGES: CLAIM HAS BEEN FORWARDED TO PAYER FOR CONTINUED PROCESSING (60054)

848 10079             CRUSHER            WESLEY       20050307    111.00  60054
  CLAIM PROCESSING DATE: 20050311
  CAPARIO TRACE #: 000000000000003 VAN: 848 10079       PAYOR:
  MESSAGES: CLAIM HAS BEEN FORWARDED TO PAYER FOR CONTINUED PROCESSING (60054)

1068 10080            DUCK               LOUIE        20050308     81.00  60054
  CLAIM PROCESSING DATE: 20050311
  CAPARIO TRACE #: 000000000000004 VAN: 848 10079       PAYOR:
  MESSAGES: CLAIM HAS BEEN FORWARDED TO PAYER FOR CONTINUED PROCESSING (60054)

--------------------------------------------------------------------------------
TOTAL CLAIMS ACCEPTED BY CAPARIO:  3                   CHARGES:  357.00

The report above shows one claim that was rejected because of a faulty diagnosis code and three claims that were processed and passed on to the insurance company.

Capario (ProxyMed) Payor Response Report

This report shows problems, errors, and accepted claim information that Capario received back from the payor. You will receive this report from ProxyMed once all the insurance carriers have responded to them. Since this report may contain payor rejections, you should read this report every time you receive it.

Payor Rejections, Not ProxyMed Rejections. Errors and rejections in this report come from the payor. Even though ProxyMed collects this information and sends it to you, the insurance carrier is the author of the rejection.

================================================================================
 ProxyMed Payor Response Report          Date Printed:  3/12/2005      Page   1

 The following claims were ACCEPTED by the payor(s).

   PATIENT/            PATIENT           PATIENT      SERVICE     CLAIM   PAYOR
   CLAIM ID           LAST NAME         FIRST NAME      DATE     CHARGES   ID
================================================================================
394 10078         DOE                  JOHNNY         20050308     165.00 60054
  CLAIM PROCESSING DATE: 20050311 PROXYMED TRACE #: 000000000000002
  VAN TRACE #: 394 10078             PAYOR TRACE #: 0000000000001
  MESSAGES: Finalized/Payment-The claim/line has been paid.
            Payment reflects plan provisions.

848 10079         CRUSHER              WESLEY         20050307     111.00 60054
  CLAIM PROCESSING DATE: 20050311 PROXYMED TRACE #: 000000000000003
  VAN TRACE #: 848 10079             PAYOR TRACE #: 0000000000002
  MESSAGES: Finalized/Payment-The claim/line has been paid.
            Payment reflects plan provisions.

1068 10080        DUCK                 LOUIE          20050308      81.00 60054
  CLAIM PROCESSING DATE: 20050311 PROXYMED TRACE #: 000000000000004
  VAN TRACE #: 1068 10080            PAYOR TRACE #: 0000000000003
  MESSAGES: Finalized/Payment-The claim/line has been paid.
            Payment reflects plan provisions.
--------------------------------------------------------------------------------
TOTAL CLAIMS ACCEPTED BY PAYORS: 3                      CHARGES:   357.00

The above example shows three accepted claims by the payor. Common rejections you might see in this report include bad dates of service, problems with procedure codes, eligibility problems, and duplicate claim errors.

Emdeon/ENVOY Reports

Batch & Claim Level Rejection Report (RPT-05)

This report shows all claims rejected by Emdeon, with an explanation.

                       BATCH & CLAIM LEVEL REJECTION REPORT

                                    FILE SUBMISSION DATE/TIME: 01/01/05-11:20:12
 WEBMD REF: EP07608MMB83ADU                       REPORT DATE: 01/01/05
 REPORT #: RPT-05
 ACCT  ID: NOT AVAILABLE

 FILE CONTROL #: TANKQK
 SUBMITTER ID: 987654321
 SUBMITTER NAME: SOFTWARE VENDOR

 ********************************************************************************

                                 DISCLAIMER

   CLAIMS LISTED ON THIS REPORT HAVE NOT BEEN SENT ON TO THE PAYERS FOR
   PROCESSING AND MUST BE CORRECTED AND RESUBMITTED ELECTRONICALLY OR ON PAPER.

 ********************************************************************************

 CUSTOMER ID/SUB: 123456789 4963
 CUSTOMER NAME:   PROVIDER/GROUP NAME

                  **************  ERROR LISTING  **************

 PATIENT NAME           PATIENT CTRL #            CLAIM ID       DOS     CHARGES
 ________________________________________________________________________________
 DOE J                                9999    EP091305500000103 090805    160.00
 PAYER NAME/ID: ATHENS AREA HLTHCARE 95691
 ERROR MESSAGE: INV: INSURED ID
 FLD: D007    SEQ:1    FIELD NAME: INSURED ID       DATA IN ERROR: 9999999999

 FLINSTONE P                          9999    EP091305800000012 090805    275.00
 PAYER NAME/ID: BCBS OF GA ATLANTA   SB600
 ERROR MESSAGE: SUBMITTER ID IS REQUIRED BY BLUE CROSS AND BLUE SHIELD OF
 GEORGIA
 FLD:         SEQ:     FIELD NAME:                  DATA IN ERROR:

 RUBBLE B                             9999    EP091305800000014 090805    160.00
 PAYER NAME/ID: MEDICARE OF GEORGIA  SMGA0
 ERROR MESSAGE: INVALID PATIENT MEDICARE ID  99999999999
 FLD:         SEQ:     FIELD NAME:                  DATA IN ERROR:


 RPT-05

In the above example, patient J. Doe has an invalid insurance ID, the claim for P. Flinstone is missing a submitter ID, and B. Rubble's medicare ID number is invalid. Depending on the circumstances, you would review the insurance information with the policy holder, correct the information, and rebatch and resubmit the claim.

File Detail Summary Report (RPT-04)

This report shows all claims processed, accepted, or rejected by Emdeon.

                       WEBMD TRANSACTION SERVICES DIVISION
                       MEDICAL CLAIMS DISTRIBUTION SYSTEM

                            FILE DETAIL SUMMARY REPORT

                                    FILE SUBMISSION DATE/TIME: 01/01/05-14:11:21
 WEBMD REF: EP01215MPA71ABU                       REPORT DATE: 01/01/05
 REPORT #: RPT-04
 ACCT  ID: NOT AVAILABLE

 FILE CONTROL #: TANLIJ
 SUBMITTER ID: 987654321
 SUBMITTER NAME: SOFTWARE VENDOR

 ********************************************************************************

                                 DISCLAIMER

 ACCEPTED CLAIMS HAVE BEEN FORWARDED TO THE PAYER BY WEBMD TRANSACTION SERVICES
 DIVISION. ADDITIONAL CLAIM STATUS REPORTS MAY FOLLOW IF AVAILABLE FROM THE
 PAYER. THIS IS NOT A GUARANTEE OF PAYMENT.

 ********************************************************************************


 CUSTOMER ID/SUB: 123456789 1488
 CUSTOMER NAME: PROVIDER/GROUP NAME

                                   FILE ROLL-UP

 PATIENT NAME               PATIENT        DATE OF   TOTAL   PAYER NAME/ID STATUS
                           CONTROL #       SERVICE  CHARGES
 SALLY SUE            R0008693             122404    500.00 NETWORK HEAL 11315 AE
 JOHN PAIN            R0007332             121504    120.00 NETWORK HEAL 11315 AE
 JANE DOE             R0007332             121304    100.00 NETWORK HEAL 11315 AE
 NEW BORN             R0007332             122704   4000.00 NETWORK HEAL 11315 AE


                          ***  STATUS KEY LEGEND  ***

                 AE - ACCEPTED CLAIM SENT OUT ELECTRONICALLY
                 AP - ACCEPTED CLAIM SENT OUT ON PAPER
                 RE - ELECTRONIC CLAIM REJECTED BY WEBMD
                 RP - PAPER CLAIM REJECTED BY WEBMD
                 TE - ELECTRONIC TEST CLAIM
                 PA - CLAIM PENDING TESTING OR AT CUSTOMER REQUEST
                 PB - CLAIM PENDING TESTING
                 PC - CLAIM PENDING FOR INVALID OR INCOMPLETE WEBMD REGISTRATION


RPT-04

In the above report, four claims have the "AE" status. No further action is required.

Claim Status Report (RPT-10)

This report shows a record of claims accepted and their current status. The report can only display claims from those payors who return acceptance information.

                       WEBMD TRANSACTION SERVICES DIVISION
                       MEDICAL CLAIMS DISTRIBUTION SYSTEM

                           PROVIDER CLAIM STATUS REPORT

                                                          REPORT DATE: 01/07/05
 REPORT #: RPT-10

 ACCT  ID: NOT AVAILABLE

 SUBMITTER ID: 987654321                 CUSTOMER ID/SUB: 123456789 E622
 SUBMITTER NAME: SOFTWARE VENDOR           CUSTOMER NAME: PROVIDER NAME

 ********************************************************************************

                                 DISCLAIMER

  THIS REPORT IS GENERATED BY THE PAYERS AND NOT BY WEBMD TRANSACTION SERVICES
  DIVISION. NOT ALL THE WEBMD PAYERS PARTICIPATE IN THIS CLAIM STATUS REPORT
  PROGRAM AND THE AMOUNT OF INFORMATION RECEIVED VARIES FROM PAYER TO PAYER.

 ********************************************************************************

                               CLAIM STATUS

 STATUS: 1AF    ACK/RECEIPT-ENTITY ACKNOWLEDGES RECEIPT OF CLAIM/ENCOUNTER.-
 PAYER
 ________________________________________________________________________________
 PROVIDER ID:  123456789                      PAYER NAME: UNITED HEALTH CARE
 PAYER GRP #:                             PARTIAL CLAIM?:
 INSURED ID:   999999996                        PAYER ID: 87726
 PATIENT:      JOHN PAIN                     PAYER PHONE: 0000000000
 PAT CTRL #:   86370                           PAYER REF: 980123449949990
 PATIENT DOB:                          PAYER REPORT TYPE:
 TOTAL CHARGE:     78.00          PAYER STATUS DATE/TIME: 010505/00:00:00
 AMOUNT PAID:       0.00              WEBMD PROCESS DATE: 010205
 DOS:          121004-121504              WEBMD CLAIM ID: EP012305501525694
 WEBMD REF:    EP169934S2AAXXX
 DATA IN ERROR:
 ________________________________________________________________________________
 PROVIDER ID:  123456789                      PAYER NAME: UNITED HEALTH CARE
 PAYER GRP #:                             PARTIAL CLAIM?:
 INSURED ID:   999999985                        PAYER ID: 87726
 PATIENT:      JANE SYCKE                    PAYER PHONE: 0000000000
 PAT CTRL #:   86700                           PAYER REF: 980052449941600
 PATIENT DOB:                          PAYER REPORT TYPE:
 TOTAL CHARGE:    134.00          PAYER STATUS DATE/TIME: 010505/00:00:00
 AMOUNT PAID:       0.00              WEBMD PROCESS DATE: 010205
 DOS:          082405-082405              WEBMD CLAIM ID: EP123445501525712
 WEBMD REF:    EP169934S2AAXXX
 DATA IN ERROR:
 ________________________________________________________________________________

 RPT-10                    

The insurance carrier has acknowledged receipt of the two claims detailed above.

Special Handling/Unprocessed Claim Report (RPT-11)

This report shows rejections and requests for more information from the payors.

                  WEBMD TRANSACTION SERVICES DIVISION
                  MEDICAL CLAIMS DISTRIBUTION SYSTEM

              SPECIAL HANDLING/UNPROCESSED CLAIMS REPORT

                                                   REPORT DATE: 01/07/05
 REPORT #: RPT-11

 ACCT  ID: NOT AVAILABLE

 SUBMITTER ID: 987654321                 CUSTOMER ID/SUB: 123456789 J027
 SUBMITTER NAME: SOFTWARE VENDOR           CUSTOMER NAME: PROVIDER NAME                 


                               CLAIM STATUS

 STATUS: 5Z     INCOMING PROVIDER DATA INVALID OR MISSING - PLEASE CALL CARRIER
 FOR FURTHER INSTRUCTIONS ON THIS CLAI
 ________________________________________________________________________________
 PROVIDER ID:  X99999038                      PAYER NAME: BOSTONMEDCNTRHEALPLAN
 PAYER GRP #:                             PARTIAL CLAIM?:
 INSURED ID:   123999983                        PAYER ID: 13337
 PATIENT:      JOYCE DOE                     PAYER PHONE: 6177488000
 PAT CTRL #:   0100065877                      PAYER REF: E00349330700
 PATIENT DOB:                          PAYER REPORT TYPE:
 TOTAL CHARGE:    360.00          PAYER STATUS DATE/TIME: 010505/00:00:00
 AMOUNT PAID:       0.00              WEBMD PROCESS DATE: 010205
 DOS:          122604-122604              WEBMD CLAIM ID: EP012305500906546
 WEBMD REF:    EP250344OOAAXXX
 DATA IN ERROR:
 ________________________________________________________________________________


 RPT-11  

In the above example, Joyce Doe's claim was missing incoming provider data. After checking the provider ID information, you would probably contact the carrier as instructed in the status message.

McKesson Reports

McKesson Claims Acknowledgment

This report is a record of all the claims McKesson received during a particular submission. You should receive this report within 48 hours of claim submission. All claims, whether perfectly formatted or containing errors, will be listed as shown below. This report is a useful reference when trying to track the progress of an unpaid claim; it serves as a "paper-trail" proving that McKesson received the claim.

                        CLAIMS ACKNOWLEDGMENT REPORT                  PAGE:  1  
 CPI999.01                                                            03/11/2005
 PROCESSING DATE: 03/11/2005                                          01:21:44  
 *******************************************************************************
 000000-BEDROCK PEDIATRIC PRACTICE                CLAIM BILLING DATE: 03/10/2005
 000000-SMITH, JANE J MD                                                        
 *******************************************************************************
  PATIENT / CLAIM            PATIENT NAME             CLAIM        CLAIM   D E S
     ID NUMBER           LAST            FIRST   MI FROM DATE      AMOUNT  C F C
  *************** ******************** ********** * **********    ******** * * *
          AETNA                             CPID: 6400
  243 10077       FLINTSTONE           PEBBLES      03/08/2005      111.00 E E
   TSH CLAIM ID: 0000000000000000001   CLAIM ID:  243 10077                   
  394 10078       DOE                  JOHNNY       03/08/2005       65.00 A
   TSH CLAIM ID: 0000000000000000002   CLAIM ID:  394 10078 
  848 10079       CRUSHER              WESLEY       03/07/2005      111.00 A
   TSH CLAIM ID: 0000000000000000003   CLAIM ID:  848 10079 
  1068 10080      DUCK                 LOUIE        03/08/2005       81.00 A
   TSH CLAIM ID: 0000000000000000004   CLAIM ID:  1068 10080 
                       TOTALS FOR CPID 6400:               4        468.00     0
 *******************************************************************************
 CPID 6400:            ACCEPTED                            3        357.00     0
                       EXCLUDED                            1        111.00     0
                                                                                
 000000 TOTALS:        ACCEPTED                            3        357.00     0
                       EXCLUDED                            1        111.00     0
                                                    ********  ************  ****
                       TOTAL-INPUT                         4        468.00     0
                       *********************************************************
                       (A) ELECTRONIC TO PAYER             3   +    0   =      3
                       (E) PAPER CLAIM-MAILBOX             1   +    0   =      1
                                                    ****************************
                       TOTAL OUTPUT                        4   +    0   =      4
 *******************************************************************************

                           SUMMARY TOTALS BY CPID                               
                NUMBER OF     SUPPLEMENTAL       TOTAL             CLAIM        
     CPID        CLAIMS          CLAIMS          CLAIMS            AMOUNT       
    ******     **********     ************     **********     **************    
    6400               4                0              4             468.00     
               ----------     ------------     ----------     --------------    
    TOTALS             4                0              4             468.00

The above example shows four claims that were processed by McKesson.

McKesson Exclusion Claims

This report shows a list of claims that McKesson could not send on to the payor. This report will be sent to you at the same time as the McKesson Claims Acknowledgement report, usually within 48 hours of claim submission. Since this report contains a list of problem claims, you should read it every time you receive it.

                            EXCLUSION CLAIMS REPORT                  PAGE:  1  
 CPI999.01                                                            03/11/2005
 PROCESSING DATE: 03/11/2005                                          01:21:44  
 *******************************************************************************
 000000-BEDROCK PEDIATRIC PRACTICE                CLAIM BILLING DATE: 03/10/2005
 000000-SMITH, JANE J MD                                                        
 *******************************************************************************
  PATIENT / CLAIM            PATIENT NAME             CLAIM        CLAIM   D E S
     ID NUMBER           LAST            FIRST   MI FROM DATE      AMOUNT  C F C
  *************** ******************** ********** * **********    ******** * * *
          AETNA                             CPID: 6400                          
  243 10077       FLINTSTONE          PEBBLES       03/08/2005      111.00 E E
   TSH CLAIM ID: 0000000000000000001  CLAIM ID:  243 10077  
 FT  0002D:INVALID DIAGNOSIS CODE POINTER                                     UB
                       TOTALS FOR CPID 6400:               1        111.00     0
 *******************************************************************************

The above excerpt shows a claim from 03/08/2005 that was rejected due to a diagnosis code problem. Keep in mind that such a claim has not been sent to the payor. You should correct the error and rebatch the charges in question.

McKesson Carrier Acknowledgement

This report is a catalog of responses from all the different payors. McKesson collects payor responses and sends them to you in this report as soon as they are all received. Reading this report is difficult because every insurance company has their own style and layout for responding. This report contains errors and rejections from insurance companies, so you must read through this report whenever you receive it.

McKesson Monthly Summary

This report is a summary of your claim activity with McKesson. Not all of your claims go through McKesson, but it can still be a useful reference for keeping track of your claim volume.