Read EDI Responses to Claim Submissions

After you submit claims, your office receives many different electronic responses. Your PCC system logs submission activity, PCC’s central server sends your system a daily summary, claim clearinghouses and other vendors send back acknowledgment reports, and payers send back rejections and ERAs.

Read the sections below to learn what kinds of responses are sent to your practice, which you should review, and where you can go to research responses when you run into a billing problem.

What is "EDI"?: EDI stands for “Electronic Data Interchange.” When you submit electronic claims or receive any kind of electronic reports, you are using EDI. PCC has several different dedicated teams working on EDI, and you can contact PCC Support with any questions.

Learn All Steps for the Biller Role: This article is part of the New User Training for Billers. You can use that outline to learn how to complete all billing tasks in PCC EHR.

What EDI Responses Are Sent To Your PCC System?

PCC, claim clearinghouses, ebill vendors, and payors all send your practice various electronic communication.

Electronic personal bills are fairly straightforward: Your PCC system logs what went out on the bills, and the ebill vendor sends back an acknowledgement that bills were received.

Claims, however, result in a series of logged information, responses, and reports:

For most of these responses, your PCC system automatically receives the report, parses it, and adds appropriate items to each family’s account history. You don’t need to review the full report file, because the information is recorded for each encounter and (in some cases) for each charge. However, the full report file is archived on your system, should you need it.

Which EDI Responses Should a Practice Review?

Which electronic responses are important to review, and which are just for reference? There are three claim responses in the chart above that your practice will always respond to:

• Need Corrections: When you process claims, your PCC system spots claim problems that need to be addressed before the claim can go out the door. You can review the “Need Corrections” claims in the PCC EHR Claims tool. Claims that are stuck also appear on the SRS Billing Error Report. Read Work on Claim Errors and Rejections to learn more.

• Claim Acknowledgements that Include Rejections: Claim clearinghouses and payors will sometimes send your practice rejections, which indicate that the payor will not adjudicate the claim. You can find rejected claims in the SRS Billing Error Report or review them in the encounter’s Claim History in the Billing History in the chart. Read Work on Claim Errors and Rejections to learn more.

• 835s (ERAs): After a claim is adjudicated, payers typically send an 835 ERA file, which explains payments, adjustments, and denials. These ERAs replace a traditional paper EOB. Your practice can automatically post most of these payments, and then manually post any that did not match expectations. Read Post Insurance Payments to learn how to post your ERAs. Later, you can review archived responses in the Electronic Remittance Advice tool.

How Do I Review the Archived Copy of any EDI Response?

As described above, PCC included many powerful tools and reports for addressing claim and billing problems.

• You can review original claim files, acknowledgements, and other reports in the Billing History section of the patient’s chart.
• You can read the full ERA in the Electronic Remittance Advice tool.
• You can read all archived EDI communication in the EDI Reports (ecsreports) program, which includes acknowledgements from your third-party bill printing service, batch reports for a day’s submission, and copies of all other archived output from electronic transactions.