eClaims in MacPractice utilizes the standard 837 Transaction Sets, ASC X12N 837, ANSI 4010 and also 5010. MacPractice will continue to support 4010 for the foreseeable future. Please note that some new requirements for 5010 may require you to update to MacPractice version 4.1 or greater. If you have any questions about the eClaims format or any updates for ANSI 5010, please contact the EDI division of the MacPractice Support department at 877-220-8418.
It is important to note that a paper claim will not necessarily reflect the information that appears on an electronic claim. Many payers have very different requirements for eClaims than they do for paper claims. Printing out a paper claim to verify information regarding an eClaim will not be helpful, because the information won't always match between the two media.
Links to other eClaim related articles:
- eClaims Terminology
- Creating an eClaim
- Secondary eClaims
- The Rebuild Button
- eClaim Templates
- The ProxyMed Template
- DentalXchange and the EHG Template
- eClaims Ability Usage Guide
- Common Medicaid Billing Situations
Before you can send electronic claims, you will need to begin the enrollment process with one of our clearinghouses. Please contact the MacPractice Enrollment department at 877-220-8418 if you have not enrolled for eClaims. After your enrollment, you will receive an eClaims training, during which the eClaims trainer will install and set up your eClaims template. This documentation has been written to provide you with additional information after your eClaims template has been installed and your eClaims training has been completed. This document is in no way meant to replace eClaims training. Before training, MacPractice recommends that you familiarize yourself with the MacPractice Ledger, and make sure you know how to enter procedures, post payments and create paper claims. Please review the Ledger documentation if you need assistance with this process.
The eClaims ability is divided up into 3 panes. The area along the top contains 7 different tabs listing different claim statuses. Your claims will be listed under the tab corresponding to the appropriate status (A). When you have a claim selected, the area near the bottom left will display the claim details, listing all information on the eClaim (B). The area on the bottom right will display the status updates and history for the selected claim, with the most recent information listed first (C). You will utilize this area to review problems with invalid and rejected claims, and can also use this information to see exactly when claims were sent, received, and so on.
As you work with your electronic claims, they will be moved from tab to tab in the eClaims ability as their status changes. Each tab will also display the number of claims within the tab next to the name. If you do not see a number, it simply means MacPractice is currently loading that information. If you are in Many mode (that is, you don't have a patient selected), you will see all patients' claims of a given status within the tab.
If you are in One mode (that is, you have a patient selected), you will only see that patient's claims. The number next to the status name will also show you how many claims you are viewing out of the total number of claims in that status. In the example below, we are viewing 2 out of 42 invalid claims. If a bin contains only s claims for other patients than the one that is selected, the bin will appear empty to the viewer. The numbers in the title tab will indicate there are claims in the bin, even if they cannot be viewed.
You may manually change the claim status in the eClaims ability by selecting the claim, and using the "Move To" pop-up menu (A). Changing the status in the eClaims ability will also change the status in the patient's ledger as well. You should take caution when manually changing claim statuses however, as changing the status incorrectly may prevent the claim from being sent or processed.
If you have multiple templates in your database, you can also filter your eClaims list by the template, by selecting the template in the "Template Filter" pop-up menu (B). You cannot use this feature to change the template that the claim was created with. If you created a claim with the wrong template in error, you will need to create a new claim using the correct template. If the original claim has not been sent, you can delete it; if it has been sent to the clearinghouse, you should close or archive the original claim.
Select a claim in the upper pane to edit the claim or review the claim details. With a claim selected, the bottom left hand area will show you the current information listed on the claim, including the provider, patient, primary, and procedure information, among others. This area should not generally be used to edit the claim information, because it does not fix the source of the problem. MacPractice recommends making the change in the patient's record, and simply fetching the updated claim information in the eClaim itself by clicking the Rebuild button. Utilizing this method will fix the source of the problem, so that it does not occur again. If you make the change in the claim data in the eClaims ability, it will only temporarily fix the issue on the selected claim. Rebuilding the claim at any point will remove any data you have manually entered into the claim details.
There are occasions in which the Rebuild button won't update new information. For further details on when not to use the Rebuild button, click here.
Claims will be assigned a status when they are initially created. The initial claim status will either be Invalid or Ready. Ready claims are claims that pass MacPractice validation and are ready to be set to the clearinghouse for transmission. Invalid claims have failed MacPractice validation and need to be reviewed before they can be sent. To review an invalid claim, select it in the eClaims ability. The pane in the bottom right hand corner will show you details about why the claim is invalid.
Missing information in the patient's demographics, the insurance company information or the provider's credentials could potentially cause an invalid claim, among other things. The types of invalid messages you receive will depend on your template. For example, the ProxyMed template for medical claims submitters will stop claims that do not have any diagnosis codes, but the EHG template for dental submitters will not.
Invalid claims will also be highlighted in red in the table above, and the area where the information is invalid will be highlighted in red in the claim data section. MacPractice recommends changing the source of the problem and the rebuilding the claim instead of manually fixing the information here.
Once you fix all issues with your invalid claim, select it and click the Rebuild button. As long as all issues with the claim have been addressed, it will be moved to the Ready tab. You will notice after a claim has been rebuilt, that the status area will change to show you which user rebuilt the claim and on what date.
Once you are ready to send your claims, make sure you have the Ready tab selected, and click the Send button.
Please note that if you select a claim, only that single claim will be sent. If you would like to send all claims, either select all claims or make sure you don't have any claims selected when you send. When you click Send, MacPractice will display an alert, telling you how many claims you are sending. Click OK. The software will generate your claim data and upload it to the clearinghouse. You may see MacPractice spin for a short while here, depending on the speed of your internet connection and the number of claims being submitted. Please do not force quit this process. After uploading, you will receive a pop up menu letting you know whether your claims have sent successfully or not. If claims have been sent normally, the File Transfer Results window will say "Command Succeeded, Client exited with (0)" near the bottom of the window.
If you see anything other than "Command Succeeded," please check your internet connection and try again after a few minutes. If you continue to experience issues with claims submission, please contact MacPractice support.
Once your claims have sent, they will be automatically moved to the Sent tab. Generally speaking, you can upload your electronic claims as often as you like, however MacPractice recommends sending claims at least once a day to expedite the claims process. The availability of additional tracking at this point depends on what kind of template you are using.