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.

Contents

1 What EDI Responses Are Sent To Your PCC System?
2 Which EDI Responses Should a Practice Review?
3 How Do I Review the Archived Copy of any EDI Response?

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 Claims That Cannot Be Submitted to learn more.
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 Insurance Balances tool or review them in the encounter’s Claim History in the Billing History in the chart. Read Work on Claim 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 includes tools and reports for addressing claim and billing problems as part of your daily workflow. You can also read EDI responses for any encounter.

Claim History: You can review original acknowledgements and other responses using the Claim History for any encounter. The Claim History is available on the Posting Exceptions detail view, but you can find it at any time for any encounter in the Billing History section of the patient’s chart.
All ERAs: As described above, you can read the full ERA in the Electronic Remittance Advice tool.
System Archive: If you don’t know the patient, check number, or payor you can also read archived EDI communication that arrives on your PCC system in the under-the-hood EDI Reports (ecsreports) program. In addition to claim responses, the archive includes acknowledgements from your third-party bill printing service, batch reports for a day’s submission, and copies of other archived output from electronic transactions.

Here are some related articles in Billing and Practice Management > Bill Insurance:

Work on Claim Errors, Rejections, and All Unpaid Claims
After you prepare and submit claims, you must deal with claims that could not be submitted or were rejected.
Submit Claims
Use the Claims tool to process and submit claims to insurance companies and other payers, work on claims that could not be submitted, and review a log of submissions.
Review Archived EDI Reports
After you submit claims, your practice will receive clearinghouse and payor acknowledgements as well as ERAs and other electronic notifications from PCC, claim clearinghouses, and payors. You can use tools in PCC EHR to review these responses. When you need to do deeper research, you can use the EDI Reports (ecsreports) program.
Insurance Billing Overview
PCC's insurance billing tools help you process and prepare claims, send them electronically or print them, review rejections and denials, fix problems and resubmit, and work down your insurance accounts receivable. You can maximize the use of your time as you pursue proper insurance reimbursement.
Print Paper HCFA Claim Forms
While most claims are transmitted to payors electronically, sometimes you may need to generate paper 1500 HCFA forms, or print a single paper claim.
The Claim Journey Explained
How is a claim created, and what happens in the background to make sure your practice is paid? Read below to learn some of the "under the hood" workings of claims after you post charges into PCC EHR.
Edit the Insurance Plans On Your PCC System
Use the Tables tool in the Configuration menu in PCC EHR to update the list of plans that your practice bills.
Add an Attachment Code to a Claim
If a secondary insurance requires the EOB from the primary, or any claim requires a certificate of medical necessity, discharge summary, or other clinical documentation, you need to send an attachment to the payor. You can edit the encounter and add an attachment code to an encounter, generate a unique attachment ID, and specify the attachment type and method. Attachment information will then be sent with the electronic claim.
Configure Capitation and Capitated Plans
Capitation payments are not like other income. How should you configure PCC EHR in order to track payments you receive as part of your participation with a capitation insurance plan? PCC Support will complete the steps in this article for you, but you may find the instructions helpful if you are a system administrator or practice manager and make updates to your PCC tables.
Edit the Insurance Plans on Your PCC System
Use the Tables tool in PCC EHR to add a new insurance plan and configure the payors you send claims to.
Submit Claims
Prepare and submit claims. Then work on any claims that were stuck and couldn't be submitted.
Configure Claim Holds and Claim Delay
Watch this video to learn how to hold claims for specific providers, locations, or plans and how to configure your practice's claim delay.
Configure Claim Holds and Claim Delay
When your practice needs to prevent certain claims from being submitted, you can create a claim hold. A claim hold prevents claims from going out for specific dates of service, billing providers, places of service, and insurance plans. You can also configure your practice’s claim delay, which prevents any claim from going out until a certain number of days after the date of service.
Claim Processing and Needs Correction Error Reference
What kinds of pre-submission processing does your PCC system do on claims? What errors can it find, and how do you fix them?
Track Newborn Charges and Delay Billing the Family
If you bill for newborn encounters before the family has updated their insurance, will your PCC system send them a large bill? Your practice can add a newborn patient to your PCC system, track newborn hospital and office encounters, and delay billing until the family has updated their insurance information. Read below to learn more.
Respond to Claim Rejections
If unaddressed, rejected claims result in lost revenue. Use the Rejected Claims worklist to review and respond to every claim rejection sent to your practice.
Respond to Claim Rejections
If unaddressed, rejected claims result in lost revenue. Use the Rejected Claims worklist in the Insurance Balances tool to review and respond to every claim rejection sent to your practice.

What EDI Responses Are Sent To Your PCC System?

Which EDI Responses Should a Practice Review?

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

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