eClaims - Claims are being denied for showing as a capitated encounter?

This issue usually comes to light when the office speaks to a payer about a vague denial, since there is no claim adjustment reason code or remittance advice remark code to indicate this problem. The payer tells you that the claim has come across as a capitation encounter. It should have gone across as a claim. How does this happen?

The greatest likelihood is that the claim is being sent to an incorrect payer ID. Many payers process electronic encounters as well as electronic claims. MacPractice does not have the ability to create and send electronic encounters, only electronic claims. Usually, the word "Encounters" is part of the payer name, to indicate encounter only processing.

AvMed is a good example of a payer that processes electronic encounters. Running a search for AvMed at the Capario Payer List will produce a number of results. Note that the Payer Name for Payer ID '59275' is AvMed Encounters. Any claims that go to this payer through Capario will be flagged as an encounter for capitation. The claim will then go to the payer's capitation encounter processing system, rather than the electronic claim processing system. The resulting response from any eClaim sent from MacPractice will be a denial of payment.

The proper ID to which electronic claims should be sent would be '59274', for AvMed Health Plan.

If there is no plan associated to the patient, to correct the issue, go into the Insurance Reference and change the Claims Payer ID in the Company Info tab to direct eClaims to the correct payer ID. Replace the payer ID for the company's "encounters" processing with a payer ID that is listed for that payer name without "encounters" in the name.

If there is a plan associated to the patient, to correct the issue, go into the Insurance Reference > Plans tab and select the associated plan in the side panel. From there, select the Demographic sub-tab and change the payer ID in the Claims Payer ID field to that of the payer that does not have "encounters" included in the name.

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