eClaims - Terminology

Before your eClaims training you may want to familiarize yourself with some eClaim terminology. You will want to be familiar with the terms listed below. Please review the Glossary for a full list of terminology.

Change Healthcare (n., EDI) A medical claims clearinghouse supported by MacPractice. Change Healthcare may also be known by its former names, Capario, MedAvant or ProxyMed.

clearinghouse (n., EDI) A central institution or agency for the collection, maintenance, and distribution of electronic data. Clearinghouses will transmit and convert electronic data for a payer. Some clearinghouses will even process claims.

DentalXChange (n., EDI) A dental insurance claims clearinghouse supported by MacPractice. DentalXChange may also be referred to as EHG, their company name, or ClaimConnect, the name of their website.

eClaim (n., EDI) An insurance claim that is sent electronically.

EDI (n.) Abbreviation for Electronic Data Interchange. The exchange of standardized document forms between computer systems for business use. The EDI department at MacPractice handles all electronic claims, electronic remittance advice and electronic statements, as well as real-time transaction support through our clearinghouses' portal services.

EFT (n.) Abbreviation for electronic funds transfer. If the provider has an EFT agreement with a payer, the payer will deposit funds into the provider's bank account via an automated (banking) clearinghouse (ACH). In MacPractice, users can flag insurance payments as EFTs, and will then have the option to exclude EFT from the deposit slip.

ERA (n., EDI) Abbreviation for electronic remittance advice. Sometimes known as an ERN or Electronic Remittance Notice, an ERA is an electronic version of a remittance, also known as an EOB or Explanation of Benefits.

legacy (adj., claims) Used to refer to non-NPI identifiers that may still be sent on claims. Sometimes also called PIN numbers or PTANs.

NPI (n., claims) Abbreviation for National Provider Identification. The NPI is a 10-digit unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses will use the NPIs in the administrative and financial transactions adopted under HIPAA. After May 23, 2008 the NPI must be used in lieu of legacy provider identifiers in all HIPAA-standard transactions.

payer (n., claims) An entity who pays a provider for services rendered to a patient. This includes but is not limited to insurance carriers. Not all payers are insurance carriers, not all insurance carriers are payers.

payer ID (n., EDI) An identification number for a payer that is required for electronic claims submission. Payer IDs are specific to each clearinghouse for each payer.

portal (n.) A website run by a clearinghouse or payer which allows access to certain aspects of their data systems. Portals allow providers to perform real-time transactions such as eligibility checks, claims status inquiries, and real-time claims submission as well as viewing claim data.

provider (n.) An entity who renders services to a patient. This includes but is not limited to doctors.

PTAN (n., claims) Abbreviation for Provider Transaction Access Number. Also known as a provider PIN number or a Legacy number. Providers typically do not send these numbers on claims after the May 23rd, 2008 NPI only date but they might still need these numbers for Medicare enrollment and Medicare eligibility checks.

submitter (n., EDI) Any entity who submits claims directly to a payer or trading partner.

trading partner (n., EDI) A secondary clearinghouse that acts as an intermediary between one clearinghouse and the payer.

Invalid v. Rejected v. Denied claims
The difference between invalid, rejected, and denied claims Claims sent electronically can be either rejected, denied or invalid. Invalid claims are stopped by MacPractice because of missing or incomplete claim information. MacPractice cannot filter for all billing criteria, but the software can catch some major issues before they get sent, enabling you to resolve issues quickly.

Rejected claims are stopped either by a clearinghouse, trading partner or payer's front end computer. Since rejected claims are stopped by a computer, the response is sent back electronically with your eClaims reports. Rejection messages allow you to receive information back on your eClaims much faster than you would with a paper claim. Because of their nature, rejection messages can be difficult to decipher. The MacPractice Support Department will assist with electronic claim rejections if using one of our dedicated clearinghouses.

Denied claims have passed every computer edit but were denied by the Payer's claims processing floor. Denials will come back to a provider via an EOB or ERA. Claims are typically denied for billing issues, which MacPractice cannot advise on. The payer should be the first line of contact for denials, as they are the source of the denial.

The difference between credentialing and enrolling
Being credentialed refers to having Provider information on file with a Payer for the purpose of sending claims. The office is responsible for all Payer credentials. MacPractice cannot offer any assistance or advice with the credentialing process, however Medicare requires an 855 form to be completed to gain acceptance into the Medicare program. Visit CMS for more information on the credentialing process. Many payers use the terms credentialed and enrolled interchangeably, therefore MacPractice uses the term enrollment to refer exclusive to EDI enrollment.

Several payers require an additional enrollment to send electronic claims. This might be known as an EDI enrollment, EDI agreement, Submitter agreement, and so forth. The MacPractice Enrollment Department will assist with the eClaims enrollment process if using one of our dedicated clearinghouses. To make sure the enrollment process goes smoothly, please make sure to provide all requested information and make sure that all credentials are up to date with all Payers.

The difference between Accepts Assignment and Participate
Accepts Assignment means that the provider accepts the carrier's allowed amounts. Definitions of Accepts Assignment vary by payer, the provider should contact the payer for clarification. Generally it means that the provider will receive the payment for the visit. For Medicare, Accepts Assignment means that the provider agrees to Medicare's allowed amount for the procedure and cannot charge the patient more than the contracted allowed amount. The provider needs to either use Medicare's fee schedule or needs to write off the difference between the office charge for the fee and Medicare's allowed amount.

Participate means that the provider is a participating provider with that carrier's network, or an in-network provider. Definitions of Participate vary by payer, the provider should contact the payer for clarification. For Medicare, participation means the provider agrees to always accept assignment of claims for all services furnished to Medicare beneficiaries. By agreeing to always accept assignment, the provider agrees to always accept Medicare-allowed amounts as payment in full and to not collect more than the Medicare deductible and coinsurance from the beneficiary.

The difference between Individual NPI and Group NPI
Individual NPI also often referred to as Type 1 NPI is a unique identifier that is associated with a person that provides healthcare services and submits medical or dental claims. The Individual NPI is used for the purpose of identifying a rendering provider.

A provider may maintain their Individual NPI if they move from one practice to another. All individuals that provide healthcare services and submit medical or dental claims are required to have an Individual NPI.

Providers can often bill using their Individual NPI numbers, but cannot usually bill using another provider's Individual NPI number.

Group NPI also often referred to as Type 2 NPI is a unique identifier that is associated with an organization that provides healthcare services and submits medical or dental claims.

An organization will retain the same Group NPI even as providers leave and join the practice. Often, when a clinic or office takes on a new owner and the name of the practice changes, they will be required to obtain a new Group NPI to take the place of the existing NPI.

Any number of providers can bill under the same Group NPI, as long as they are on file with insurance companies to do so.

Note that not everyone has a group NPI. Sole practitioner's often have only an Individual NPI, but a sole practitioner's practice may possess a Group NPI if the practice has an incorporated federal tax ID number.

An outline for your eClaims training will also be provided to you by the eClaims trainer before your training. These outlines are also listed below.

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