| EDI Reports (ecsreports) | ||
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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.
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
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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 rebatched in oops. It may already have been rebatched, but you should review the account to be certain.
Other common errors on this report include missing birthdates and bad addresses.
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.
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 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
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The above section shows that PCC received and processed four Aetna claims On March 10, 2005.
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
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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.
This report shows problems, errors, and accepted claim information that Capario received back from the payor. You will receive this report from Capario 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 Capario Rejections. Errors and rejections in this report come from the payor. Even though Capario collects this information and sends it to you, the insurance carrier is the author of the rejection.
================================================================================
Capario 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 CAPARIO 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 CAPARIO 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 CAPARIO 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.
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 PAGE 1
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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.
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 PAGE 1
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In the above report, four claims have the "AE" status. No further action is required.
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 PAGE 1
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The insurance carrier has acknowledged receipt of the two claims detailed above.
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 PAGE 1
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In the above example, Joyce Doe's claim was missing incoming provider data. Afer checking the provider ID information, you would probably contact the carrier as instructed in the status message.
This report is a record of all the claims RelayHealth 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 RelayHealth 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
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The above example shows four claims that were processed by RelayHealth.
This report shows a list of claims that RelayHealth could not send on to the payor. This report will be sent to you at the same time as the RelayHealth 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.
This report is a catalog of responses from all the different payors. RelayHealth 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.
This report is a summary of your claim activity with RelayHealth. Not all of your claims go through RelayHealth, but it can still be a useful reference for keeping track of your claim volume.