An eClaims trainer will install and configure the eClaims template for the office before claims can be created and managed.
CDA Initial Setup
To configure CDA eClaims, first set the Localization panel in Preferences to "Use Canadian Claim Fields". Within the MacPractice menu, select Preferences > Localization and set any menu to the desired unit.
Note: Use Canadian Claim Fields should default all dropdown menu items to proper settings for the region. Additional changes can be made after checking this box.
CDA User Setup
Set up each provider with a User in MacPractice. In the References ability, select Users and create a new User if necessary.
- Check the Is Provider checkbox to define the User as a provider within MacPractice menus.
- Set the Provider Shown on Claim for any nurses, hygienists, and so on where a doctor should appear claims.
- The Patient Provider option in the Provider Shown on Claim option should only be used if the provider bills under his/her own name.
In the Provider Numbers tab, enter the Provider ID number in the SSN/Provider ID field, the Billing Provider number in the Federal/Billing Provider field, and the Billing Office number in the Sub ID/Billing Office # field. These numbers are provided by iTrans.
CDA Patient Setup
Each patient is set up within the Insurance box in the Primary or Secondary tab.
- For all patients, enter the patient's insurance on the guarantor screen in the Insurance box.
- Enter the Subscriber ID number and Group Policy number, if applicable.
- Enter a Renewal date, Division/Section number, or Sequence/Version number if these numbers are assigned by the patient's carrier. Leave these fields blank if there is no corresponding number.
- The Start and End Date fields may be entered to track the patient's insurance start date and end date. The Start Date is required for any eligibility checking. The End Date field will only be used if the patient's coverage is terminated.
On the Patient tab, enter the Marital and Employment status, Relationship to Primary/Secondary, Language, School Information, and Patient Exception code as applicable. These fields are on the right side of the Patient screen, under the Pop-Ups and CDA tabs.
The insurance company is also listed under the patient's Insurance tab. Scroll to the right to see a Dependent Code field and a Check Eligibility button where the company has made eligibility checking available. Check with the carrier for more information. Not all payers support eligibility checking. If the payer supports eligibility checking, click this button to retrieve eligibility reports for the selected patient. View the eligibility reports in the eClaims ability under Reports.
CDA Insurance Setup
To configure an insurance for use with eClaims, select the Insurance Company in References and create a new insurance reference if it does not already exist.
- On the Company Info tab, enter the CDAnet ID for the insurance carrier as assigned by iTrans.
- In the Network field, select the network from the dropdown menu. A list of CDAnet IDs and network names can be found in the Supported Transactions list.
On the Provider IDs tab of the Insurance Reference, check the Provider Accepts Assignment checkbox if the provider should receive payment for services. Enter a date in the Reconciliation Date field. The Reconciliation date is required for payment and summary transaction reports. This preference will also default to the ‘accepts assignment’ dropdown in the patient ability on the Primary/Secondary tab.
A preference commonly related to providers accepting of assignment with a carrier is Preferences > Claims > Automatically Close New Claims If Provider Does Not Accept Assignment. This way if the patient gets paid by the insurance, there won't be a large amount of outstanding claims.
Note: Scroll to the far right to see these columns. Columns can be rearranged with the CDA columns first, as the other fields are only used for US claims.
On the CDA tab, check the CDA version, Network, and Supported Transactions for each insurance company. This information is found on the Supported Transactions list.
CDA - Managing eClaims
With the provider, patient, and insurance records configured, claims can be created after the eClaims training and template installation is complete. For information on creating charges or claims, please see the ledger documentation.
Created eClaims will be in the Ready or Invalid status in the eClaims ability. Ready claims have passed MacPractice validation and are ready to be sent, while Invalid claims have failed MacPractice validation due to incomplete or missing information. To correct invalid claims, select the claim from the Invalid bin and note the fields that are missing. Return to the source of the problem, enter the required information, and rebuild the claim by clicking the Rebuild button in the eClaims ability.
If a patient has a second insurance, a secondary eClaim will be created at the same time the primary claim is created. The secondary (COB) claims will also be in the Invalid status until payment is received from the primary insurance. Once the primary EOB is received through iTrans, it will be automatically associated to the secondary claim and moved to the Ready bin. Secondary (COB) claims will also be in the Invalid status if the COB is not checked on the CDA tab of the Insurance reference. This will remain Invalid until deleted. If the payer does not accept COB claims, send these as paper claims.
When the claims are ready to be sent, click on the Ready bin, select a claim, and click the Send button. Send claims one at a time, as sending claims together causes iTrans reports to be incorrectly associated to the wrong claims.
While claims are sending, a Java window will appear. This window will verify provider credentials are matching what iTrans has on file for the provider. If any errors occur during this process it is possible that provider certification is expired and keys need to be regenerated. If needed, please contact MacPractice Support for additional assistance with this process.
A File Transfer Results window will appear once claims have been sent. If sending was successful, the claim will move to the Sent bin. Claims will stay in the Sent bin until they are either Paid/Closed or manually moved to another status. Watch the Sent bin for claim aging. Claims should not reach the carrier's Age Limit, as payment will not be received once this date has passed. Sort the claims in the eClaims ability by Date Sent or Procedure Date to determine which claims are oldest, or run the claims reports in Reports > Insurance > Outstanding Claims by Insurance Company or All Outstanding Claims.
Once the claims are sent, MacPractice will download any available eClaims reports from iTrans. These reports will appear in the sidebar of the eClaims ability, under the Reports node. With the reports received, select the claim again, and click on the "Report" link to access the report under the Reports node.
Depending on the level of supported transactions from the carrier, EOBs, Eligibility Acknowledgements, Claim Acknowledgements, and Predetermination Acknowledgements may be received. Review these reports carefully. Below is an image of a sample report, however each report may be formatted differently, depending on the information the carrier supplies.
- If a Claim Acknowledgement report displays "Payee has changed total payable to dentist," this indicates "Accepts Assignment" was not checked when sending the claim and the patient will receive payment.
- Some claims have multiple reports attached to them, including some generic transaction files. Review all reports attached to a claim.
iTrans recommends that outstanding transactions are checked weekly if not daily. Create a separate Insurance reference with Payer ID 999999 and Carrier Identification # CDANET14. Click on the Provider IDs tab and click the "Outstanding" button to check for outstanding transactions from iTrans.
Once a claim is sent, the office has until the 11:59pm the day the claim was sent to send the reversal. If the claim needs to be reversed after this time please contact the carrier for further instructions.
To send a reversal, select the appropriate claim from the Sent bin and click the ‘Reverse’ button.