Questions About Claims and ERAs

Does Accepted mean we have been paid?

No. It means the payer took the claim in for processing. Payment is a separate event, and an accepted claim can still be denied. Claim Balance is what tells you where the money stands.

What does Processing cover?

Everything that is neither accepted nor rejected - including claims that have never been sent. If something has been in Processing for weeks, check first that it was actually submitted.

Why does a claim disappear from the aged views?

Those views only list claims with a balance outstanding, so a claim paid in full drops out. Clear the age filter or search for it directly.

Is the claim age counted from the visit?

No, from the date the claim was submitted. A claim sent late looks young even when the date of service is months old.

What is the difference between enrolling for claims and enrolling for ERAs?

Sending claims and receiving remittances are separate agreements, and ERA enrolment is per payer. You can be submitting successfully for months and still get paper cheques from a payer whose ERA enrolment has not completed.

Do we need to enrol each tax ID separately?

Yes. Enrolment is per business entity - each appears under Enrolled Entities with its own Account # and TaxID. Claims for an unenrolled tax ID have nowhere to go.

How often should we check for ERAs?

Pick a regular day. Remittances wait until you fetch them, and unposted ERAs make every patient balance wrong in the meantime.

What if the ERA total does not match the deposit?

Stop and look before posting. Usually a second remittance belongs to the same cheque. The Check Number on each ERA is what ties them together.

Can we post an ERA twice by accident?

Processed remittances move to PROCESSED ERAs with a Processed On date, so you can see what has been done. ReProcess exists for fixing a posting that went wrong - it is not part of the routine.

The insurer paid less than we billed. Is that a rejection?

Usually not. Contractual adjustments are the difference between your fee and the contracted rate, and they show under Adjustments / Discounts. What remains after the payment and the adjustment is the patient's or the secondary insurer's.

How do we bill the secondary insurer?

Create SECONDARY Claim Document on the claim. It carries the primary's payment and adjustments across, which is what the secondary payer needs.

A patient's details were wrong. Do we fix the claim or the patient?

The patient. Then Re-Create Claim Document so the claim is rebuilt from the corrected record. Fixing only the claim leaves the next one to reject the same way.

Every claim to one payer is rejecting. What now?

Treat it as one problem, not many. A whole payer rejecting points at enrolment or the payer ID rather than the individual claims.

What are Manual Cases?

Claims built by hand rather than generated from a visit, listed under Manual Cases with Show Complete and Show Incomplete.

Where do we see what the clearinghouse said about a submission?

BillPro Processing Reports in the billing centre - that is the clearinghouse's response to your batches, as distinct from the payer's response to a claim.