3. Verify Claim Submission (ecsreports)
3.1. Introduction: What Are EDI Reports?
Many different electronic reports are sent to your office.
Electronic Claims Reports: After you submit claims using the preptags and ECS programs, you receive a series of claim status reports and summaries.
E-Bills Reports: When you send out electronic personal bills, you receive reports about errors and which bills were sent successfully.
ERA: Some insurance carriers send an Electronic Remittance Advice (ERA), which contains an explanation of benefits that may replace the traditional paper EOB.
Eligibility: Finally, PCC creates a daily Eligibility Report for scheduled patients with participating carriers and sends it to your practice.
The sections below will teach you how to read and use the information in all of these reports.
What is "EDI"? EDI stands for "Electronic Data Interchange." When you submit electronic claims or receive electronic reports, you are using EDI. PCC has a dedicated support team for EDI issues, available at 1-800-722-1082, option 1.
Do Not Ignore Your Reports! Reading your electronic reports is a vital part of the billing process. If claims with errors or rejections are not corrected and resubmitted, you may never receive reimbursement for the work your practice performs. The sections below will teach you all you need to know to manage this task.
3.2. Accessing EDI Information
You can access EDI information in four different ways:
EDI Reports (ecsreports): All EDI reports are stored in the ecsreports program. Read below for a complete guide to using ecsreports to manage your EDI data.
E-mail: Partner can e-mail your EDI reports directly to a user or users at your practice. E-mails are not as organized or powerful as using the ecsreports program, but small offices may prefer this method. If you need to change which member of your staff receives EDI reports, contact PCC Support.
Correct Mistakes (oops): Claim EDI information for some carriers is available in the oops program. While viewing a charge in oops, you can press [F4 -- Insurance Status] and select responses for claims handled by the Emdeon or Capario clearinghouses. The relevant section of the original EDI report will appear on the screen. Read the Correct Mistakes manual for more information.
Patient Check-In (checkin): Eligibility information from participating payors is sent to your office daily. Partner pulls the most recent eligibility information for scheduled patients and displays it on the third page of the checkin program. Read the Partner Eligibility manual or Patient Check-In manual for more information.
3.3. Using the EDI Reports (ecsreports) Program
The ecsreports program shows you reports organized by date or by type. You can quickly view, print, and search reports, as well as track which reports you have printed in the past.
Because your practice receives thousands of reports every year, ecsreports does not keep all old reports on your system. Instead, reports will remain on the system for one to two years. If you would like to change the length of time that EDI reports remain on your system, contact PCC Support.
Running EDI Reports: You can run ecsreports from the Electronic Claims section of the Billing Functions window in your Partner Windows. You can also run it by typing ecsreports at a command prompt.
3.3.1. Reports By Date
The main screen in ecsreports shows you reports grouped by date:
Reports are grouped by the date they were received, with the most recent delivery date appearing at the top. For each report, you can see the title or type, the general category, the time it was received, and how many times it has been printed.
Your office can use this screen to manage incoming reports and make sure that each one is addressed. Since all ERAs should be printed, and your office may also print rejection reports, the "Times Printed" column may facilitate your workflow.
3.3.2. EDI Reports - By Report Type
Press [F8 -- List By Type] to see reports grouped by type. The "By Report Type" screen displays all report types stored on your system.
To access all available reports of a certain type, select the type and press [F1 -- Select Type]:
Reading and searching through a specific report type may be more convenient than viewing all the reports from a specific date.
Press F12 to return to the listing by date.
3.3.3. Reading Reports
Select any report, either from the main screen or from one of the "By Type" listings, and press [F1 -- View Selected] to read it:
You can select more than one report in order to view them all at once in the same window:
While viewing a report or multiple reports, you can press Page Up or Page Down to scroll. Press the End key to jump to the bottom of the report(s), press Home to jump to the top.
3.3.4. Searching While Reading a Report
While viewing a report or multiple reports, press [F8 -- Search Pattern] and enter text to perform a search:
After typing your search value, press Enter to scroll to the first matching value.
Matching items will be highlighted on the screen, and you can press [F7 -- Search For Next] to scroll through all matching results.
3.3.5. Searching Multiple Reports
You may need to search through multiple reports for a name, certificate number, or other identifier. You might not have any idea in which report the information is located, or on what date you received the information. ecsreports has a robust search engine that allows you to search through reports in several different ways.
Select Reports to Search
Select all the reports you would like to search:
Press [F6 -- Search Selected]
Press F6 to begin your search.
Search All? While reviewing reports by type, you can also press [F5 -- Search All] to search all the reports in a specific category.
Enter Search Text
On the File Search screen, enter the text for which you wish to search and press [F1 -- Process].
Whole Words? If you wish to find your text pattern only as a whole word and avoid results that contain your text pattern as part of another word, change the "Search on whole words?" question to "Yes."
Select Specific File From Results
ecsreports will list all the files from your selection that contain the text for which you searched.
Type an X next to individual reports you wish to review, or press [F3 -- Select All] to select all reports containing your search pattern.
After making your selection, press [F1 -- View Selected].
Review Result, Jump to Next
ecsreports will display the first matching result it found. The search text will be highlighted:
Press [F7 -- Search For Next] to scroll through each matching result.
Optionally, Change Search Pattern
Press [F8 -- Search Pattern] to change the search pattern. You will continue to search the same files you selected in step four above.
3.4. Working With Electronic Remittance Advice (ERAs)
An ERA is an electronic version of the traditional EOB. Instead of receiving a printed, paper explanation of payments and adjustments, an ERA arrives electronically and payment is sent separately or deposited directly into your practice's bank account. ERAs appear along with other reports on the main ecsreports screen.
You can select an ERA and view it, print it, or search it just as you can other EDI reports. Since ERAs must be posted in the Post Insurance Payments (pip) program, most users will print the ERA by selecting it and pressing [F2 -- Print Selected]. Future Partner changes will allow you to automatically post ERAs within the pip program.
On the screen, an ERA looks like this:
Use the right and left arrow keys to view the parts of the report that extend off the screen.
A printed ERA looks like this:
After you print an ERA, the value in the "Number of Times Printed" column will increase.
3.5. Which EDI Reports Should You Review?
PCC, claim clearinghouses, and carriers all send EDI reports. How do you know which reports are important to review, and which reports are merely for reference purposes?
Some reports list claim errors or problems that must be dealt with before you can receive reimbursement.
Eligibility reports tell you the insurance status of scheduled patients before they come in for their visits.
ERAs contain payment information and need to be posted against a balance in the Post Insurance Payment (pip) program.
Some reports are for reference, useful for tracking claims or understanding your office's overall claim activity.
Claim Reports: This chart shows the reports sent to a typical office as an insurance claim is processed and submitted:
While all of the EDI reports you receive contain useful information, the tables below show you which reports contain vital information that you must follow-up on and which reports are only references for later use.
3.5.1. Essential Reports
The reports in the tables below contain vital information, such as claim errors, rejections, or payment information. You should review the reports listed below as you receive them.
You Do Not Receive All of These Reports! Different offices receive different reports, based on their region and their carriers. The tables below list all reports that contain essential information, and PCC EDI Support can help you further identify which reports are important for your office.
Table 1. Essential General Reports
| Report Title | Report Category | Why Does It Matter? |
|---|---|---|
| prepags/tagsplit Bad Claims | Electronic Claims | Lists claims Partner did not process |
| Eligibility Report | Insurance Eligibility | Lists insurance eligibility data for scheduled patients |
| ERA/EOB Report | ERA/EOB | Contains remittance information |
Table 2. Essential Capario (ProxyMed, MedAvant) Reports
| Report Title | Report Category | Why Does It Matter? |
|---|---|---|
| Capario (ProxyMed) Daily Verification Report | Electronic Claims | Includes claim errors |
| Capario (ProxyMed) Payor Response Report | Electronic Claims | Includes claim errors |
Table 3. Essential RelayHealth (McKesson) Reports
| Report Title | Report Category | Why Does It Matter? |
|---|---|---|
| RelayHealth (McKesson) Carrier Acknowledgement | Electronic Claims | Includes claim errors |
| RelayHealth (McKesson) Exclusion Claims | Electronic Claims | Includes claim errors |
| RelayHealth (McKesson) Remittance | EOB/ERA | Contains remittance information |
| RelayHealth (McKesson) System Reject | Electronic Claims | Includes claim errors |
| RelayHealth (McKesson) Address Report | E-Bills | Lists electronic personal bills that require attention |
| RelayHealth (McKesson) ebills Report | E-Bills | Lists electronic personal bills that require attention |
Table 4. Essential Emdeon (ENVOY/WebMD) Reports
| Report Title | Report Category | Why Does It Matter? |
|---|---|---|
| Batch & Claim Level Rejection Report | Electronic Claims | Includes claim errors |
| Special Handling/Unprocessed Claim Report | Electronic Claims | Includes claim errors |
Table 5. Other Essential Insurance Claim Reports
| Report Title | Report Category | Why Does It Matter? |
|---|---|---|
| Availity Electronic Batch Report | Electronic Claims | Includes claim errors |
| Availity Delayed Payor Report | Electronic Claims | Includes claim errors |
| Highmark Submission Analysis | Electronic Claims | Includes claim errors |
| Anthem Midwest Clearinghouse Report | Electronic Claims | Includes claim errors |
| VT BCBS ECS Audit Report | Electronic Claims | Includes claim errors |
| TN BCBS Receipts Confirmation Report | Electronic Claims | Includes claim errors |
| VT Medicaid Claim Accept/Reject Report | Electronic Claims | Includes claim errors |
| RI BCBS Batch Control Report | Electronic Claims | Includes claim errors |
| RI BCBS Rejected Claims Error Report | Electronic Claims | Includes claim errors |
3.5.2. Reference Reports
The reports in the table below are not essential. They contain summaries and totals, claim logs, and other information that may be a useful reference later.
| Report Title | Report Category | Why Does It Matter? |
|---|---|---|
| ECS Batch Log | Electronic Claims | Lists all claims sent out from Partner |
| PCC Daily Submission Summary | Electronic Claims | Contains PCC's confirmation of claim receipt |
| RelayHealth (McKesson) Claims Acknowledgement | Electronic Claims | Contains a record of all claims RelayHealth received during a particular submission |
| RelayHealth (McKesson) Monthly Summary | Electronic Claims | Contains a summary of a month's claim activity with RelayHealth |
| Emdeon Claim Status Report | Electronic Claims | Includes claim errors and acceptances, as well as denials. |
| Emdeon File Detail Summary Report | Electronic Claims | Shows rejected claims |
3.6. 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.
3.6.1. 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 $0In 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.
- 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 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: 468.00The above section shows that PCC received and processed four Aetna claims On March 10, 2005.
3.6.2. Capario (ProxyMed) 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: 357.00The 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 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: 357.00The 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.
3.6.3. 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 PAGE 1In 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 PAGE 1In 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 PAGE 1The 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 PAGE 1In 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.
3.6.4. RelayHealth (McKesson) Reports
- RelayHealth (McKesson) Claims Acknowledgment
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 4 468.00The above example shows four claims that were processed by RelayHealth.
- RelayHealth (McKesson) Exclusion Claims
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.
- RelayHealth (McKesson) Carrier Acknowledgement
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.
- RelayHealth (McKesson) Monthly Summary
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.