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eClaims - How Does a Professional eClaim End Up in the Invalid Bin?

Professional eClaim Validation (Including ProxyMed Template)
If certain fields are not filled out within MacPractice, the information will pull blank information into the corresponding fields in the eClaim details. There are several fields within the eClaim details that, if not populated, will cause the eClaim to move to the Invalid bin in the eClaims ability.

Some items only effect the move to the Invalid bin under certain circumstances. If special circumstances are involved, they will be explained in the field description.

Certain items only cause a warning to display in the claim status panel, but don't move the claim to Invalid. Those cases will be explained in the field description.
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This document will describe the location in the claim details, accompanied by a screenshot of the location in the claim details, and a brief description of where to locate this information within MacPractice.

Provider
Provider > Office Name


The Office Name is present in References > Offices. Since there is no way to create an eClaim without office information being present, it is highly unlikely that an eClaim will be moved to Invalid based on this item missing.

Provider > Last Name


This information is located in References > Users, under the user reference for the provider that is on the claim.

Provider > First Name


This information is located in References > Users, under the user reference for the provider that is on the claim.

Provider > Submitter ID


This information is entered at the time of the eClaims training, either into the template override values or template default values. There is no reason that this information should be missing. If claims are moving to invalid for Provider > Submitter ID, please call the MacPractice EDI Department at 877-220-8418 to get this corrected.

Provider > Office Phone


This information is located in References > Offices, under the office reference that appears on the claim.

Provider > Specialty


This information is located in References > Users, under the user reference for the provider that is on the claim. It can be found under the Provider tab > Claim Credentials sub-tab, in the Provider Taxonomy (Specialty Code) field.

Provider > National Provider ID


This information is located in References > Users, under the user reference for the provider that is on the claim. It can be found under the Provider tab > Claim Credentials sub-tab, in the National Provider ID (NPI) field.

An important note regarding the provider’s NPI number: With the Change Healthcare clearinghouse, whether for dental, institutional, or professional claims, the number for every provider that submits eClaims needs to be registered at MacPractice. If an eClaim is created for a provider with an NPI that is not registered with MacPractice, the claim will move to the Invalid bin with the following message: The provider shown on this claim is not enrolled for eClaims. Please contact MacPractice Enrollments to update your enrollment information, select a different provider, or recreate as a paper claim.

If a user attempts to manually move the claim to Ready and send, they will be presented with the following alert:


Special Circumstance - Provider > Physical Address Line 1
The Physical Address Line 1 field in the claim details must be populated if the “Use Physical Address” box is checked in the claim details.


This information is located in References > Offices, in the office reference that appears on the claim, under the Physical Location tab. If the “Use Physical Location” box is checked at this location, the “Use Physical Location” box will be checked in the claim details, thus requiring that the Street Address field under this tab be filled out in order for any eClaims created using this office reference to be valid.

Special Circumstance - Provider > Physical Address City
The Physical Address City field in the claim details must be populated if the “Use Physical Address” box is checked in the claim details.


This information is located in References > Offices, in the office reference that appears on the claim, under the Physical Location tab. If the “Use Physical Location” box is checked at this location, the “Use Physical Location” box will be checked in the claim details, thus requiring that the City field under this tab be filled out in order for any eClaims created using this office reference to be valid.

Special Circumstance - Provider > Physical Address State
The Physical Address State field in the claim details must be populated if the “Use Physical Address” box is checked in the claim details.


This information is located in References > Offices, in the office reference that appears on the claim, under the Physical Location tab. If the “Use Physical Location” box is checked at this location, the “Use Physical Location” box will be checked in the claim details, thus requiring that the State field under this tab be filled out in order for any eClaims created using this office reference to be valid.

Special Circumstance - Provider > Physical Address Zip Code
The Physical Address Zip Code field in the claim details must be populated if the “Use Physical Address” box is checked in the claim details.


This information is located in References > Offices, in the office reference that appears on the claim, under the Physical Location tab. If the “Use Physical Location” box is checked at this location, the “Use Physical Location” box will be checked in the claim details, thus requiring that the Zip Code field under this tab be filled out in order for any eClaims created using this office reference to be valid.

Provider > Provider ID Type
Provider ID Type reflects the Plan Type of the insurance to which the claim is being sent. If the plan type is not a valid plan type for eClaims, the plan type will not populate this field and the claim will move to Invalid.


The plan type of an insurance is set in References > Insurance Companies, within the Claims tab. The Plan Type dropdown is where this value is set. If a plan is set for the patient, the Plan Type dropdown in the Plans tab > Coverage sub-tab will override the value that is set in the Claims tab of the insurance reference.

Below is a list of plan types that are valid for eClaims according to HIPAA, that are available to select within MacPractice:

  • Other Non-Federal Programs
  • Preferred Provider Organization (PPO)
  • Point of Service (POS)
  • Exclusive Provider Organization (EPO)
  • Indemnity Insurance
  • Health Maintenance Organization (HMO) Medicare Risk
  • Automobile Medical
  • Blue Cross/Blue Shield
  • Champus
  • Commercial Insurance Co.
  • Disability
  • Health Maintenance Organization
  • Liability Medical
  • Medicare Part B
  • Medicaid
  • Other Federal Program
  • Title V
  • Veterans Affairs Plan
  • Workers Compensation Health Claim
  • Mutually Defined

Provider > ID 1 Number


The fields that determine this are found in References > Users, under the user reference of the provider shown on the claim. In the Provider tab, under the Claim Credentials sub-tab, the Provider Tax ID on Claims dropdown will point to which field should go onto claims by default. If set to 'Use Social Security Number', then the value within the SSN field of this same tab will occupy the ID 1 Number field of the claim details. If set to 'Use Federal ID Number', the value within the Federal field of this same tab will pull to the ID 1 Number field. If the Provider Tax ID on Claims dropdown points to a field that is empty within the Claim Credentials tab, no value will pull to ID 1 Number.

Patient
Patient > Primary Relationship


If the patient's relationship to the subscriber on the claim is not a relationship that is valid for eClaims, the Primary Relationship field will show as empty in the claim details. If this field is empty, the claim will move to Invalid.

The valid relationship types are as follows:

  • Spouse
  • Child
  • Employee
  • Unknown
  • Organ Donor
  • Cadaver Donor
  • Life Partner
  • Other Relationship

Patient > Last Name


This information is located in the patient record of the patient on the claim, in the Patient tab of the Patients ability, in the Last Name field.

Patient > First Name


This information is located in the patient record of the patient on the claim, in the Patient tab of the Patients ability, in the First Name field.

Patient > Address Line 1


This information is located in the patient record of the patient on the claim, in the Patient tab of the Patients ability, in the Street Address field.

Patient > City


This information is located in the patient record of the patient on the claim, in the Patient tab of the Patients ability, in the City field.

Patient > State


This information is located in the patient record of the patient on the claim, in the Patient tab of the Patients ability, in the State field.

Patient > Zip Code


This information is located in the patient record of the patient on the claim, in the Patient tab of the Patients ability, in the Zip Code field.

Patient > Birth Date


This information is located in the patient record of the patient on the claim, in the Patient tab of the Patients ability, in the Birth Date field.

Patient Name Mismatch With Subscriber
When the patient first name, last name, middle name, and birthdate do not match exactly with the same fields in the subscriber record, and the relationship of patient to subscriber is set to 'Self', there will be a warning in the status history panel. The claim will not move to Invalid, but there will be red text at the top of the claim status history pane stating: Patient Primary Relationship is set to self but the patient and guarantor information do not match.


Primary
"Primary" in claim details refers to the subscriber for the insurance to which the current claim is being sent. Primary in the claim details does not refer to the tab in the Patients ability or the order of claim responsibility.

Likewise, Primary and Secondary Tabs in the Patients Ability do not refer to the Primary or Secondary Subscriber on insurance. These tabs indicate the personal financial responsibility regarding the patient. The secondary guarantor could very easily be the individual who subscribes to the primary insurance under which the patient is covered.

Primary > Last Name


This information is located in the patient record of the patient on the claim, in the Subscriber tab of the Patients ability, in the Last Name field. The subscriber tab in the Patients ability for the Primary node of the claim details can be the Primary tab or the Secondary tab.

Primary > Birth Date


This information is located in the patient record of the patient on the claim, in the Subscriber tab of the Patients ability, in the Birth Date field. The subscriber tab in the Patients ability for the Primary node of the claim details can be the Primary tab or the Secondary tab.

Primary > Address Line 1


This information is located in the patient record of the patient on the claim, in the Subscriber tab of the Patients ability, in the Street Address field. The subscriber tab in the Patients ability for the Primary node of the claim details can be the Primary tab or the Secondary tab.

Primary > City


This information is located in the patient record of the patient on the claim, in the Subscriber tab of the Patients ability, in the City field. The subscriber tab in the Patients ability for the Primary node of the claim details can be the Primary tab or the Secondary tab.

Primary > State


This information is located in the patient record of the patient on the claim, in the Subscriber tab of the Patients ability, in the State field. The subscriber tab in the Patients ability for the Primary node of the claim details can be the Primary tab or the Secondary tab.

Primary > Zip Code


This information is located in the patient record of the patient on the claim, in the Subscriber tab of the Patients ability, in the Zip Code field. The subscriber tab in the Patients ability for the Primary node of the claim details can be the Primary tab or the Secondary tab.

Primary > Subscriber ID


This information is located in the patient record of the patient on the claim, in the Subscriber tab of the Patients ability, in the Insurance box, at the bottom of the screen. The insured's subscriber ID needs to be entered in the Subscriber ID # field.

Primary > Payer Identification Number OR Primary > Payer TPN
The template requires that either Primary > Payer Identification Number or Primary > Payer TPN be populated in the claim details. Both don't need to be populated, but the claim will move to Invalid if both fields are empty.


The Claims Payer ID field in the Company Info tab of the insurance reference of the payer to which the claim is being sent is where the value for Primary > Payer Identification number pulls into the claim details. If a plan is associated to the patient, the value will pull from the Plans tab > Demographic sub-tab > Claims Payer ID field.

Primary > Payer TPN pulls from the Company Info tab > Trading Partner Number field of the insurance reference o the payer to which the claim is going.

Primary > Payer Name


Primary > Payer name pulls from the insurance reference's Insurance Company field, in the Company Info tab.

Primary > Payer Address Line 1


Primary > Payer Address Line 1 pulls from the insurance reference's Street Address field, in the Company Info tab. If a plan is associated to the patient, this value will pull from the Plans tab > Demographic sub-tab > Street Address field.

Primary > Payer City


Primary > Payer City pulls from the insurance reference's City field, in the Company Info tab. If a plan is associated to the patient, this value will pull from the Plans tab > Demographic sub-tab > City field.

Primary > Payer State


Primary > Payer State pulls from the insurance reference's State field, in the Company Info tab. If a plan is associated to the patient, this value will pull from the Plans tab > Demographic sub-tab > State field.

Primary > Payer Zip Code


Primary > Payer Zip Code pulls from the insurance reference's Zip Code field, in the Company Info tab. If a plan is associated to the patient, this value will pull from the Plans tab > Demographic sub-tab > Zip Code field.

Secondary
"Secondary" in claim details refers to the subscriber for the insurance to which the current claim is not being sent, otherwise known as "Other Insurance". "Secondary" in the claim details does not refer to the tab in the Patients ability or the order of claim responsibility.

Secondary > Subscriber ID


If a patient has two insurances, the Subscriber ID field in the Secondary node needs to be populated, or the eClaim will move to the Invalid bin.

Claim
Claim > Charge Amount


If, for some reason, there is no value populated in the Charge Amount field, under the Claim node of the claim details, the eClaim will move to the Invalid bin. 0.00 counts as a valid value for this field, so the claim would not move to Invalid for a $0.00 Charge Amount. The field would need to be entirely empty for the claim to automatically move to Invalid. The field will never populate as empty unless there is an issue, or unless a user manually deletes the value from the claim details.

Claim > Diagnosis 1


Claim > Diagnosis 1 will only be empty if no charges on the claim have a diagnosis code attached. Each charge that goes onto eClaims has to have at least one diagnosis attached to it.

Add diagnoses by opening the charge window for each procedure in the patient's ledger that is going onto the claim, in the diagnosis tab of the charge window. 

Referral
Note that any validation occurring within the Referral level of the claim only moves the claim to Invalid if a referring provider appears in the claim details and required information for that referring provider is absent. If no referring provider appears on the claim, Referral validations will not move the claim, unless otherwise stated in the item explanation.

Referral > Last/Office Name


The Referral > Last/Office Name pulls onto the claim if a referral is tied to every charge in the claim. If the same referring provider is tied to every charge on the claim, it will pull the from the record in References > Referrals. 

Facility
Note that any validation occurring within the Facility level of the claim only moves the claim to Invalid if a facility appears in the claim details and required information for that facility is absent. If no facility appears on the claim, facility validations will not move the claim, unless otherwise stated in the item explanation.

Facility > Name


This field will pull to the claim if the same facility reference is tied to each charge on the claim.The facility is added to the charges by selecting it in the charge window for the procedures on the claim. If the same facility is tied to each charge on the claim, Facility > Name will pull from the record in References > Facility.

This validation is to ensure that there is a facility on the claim if the place of service code for any procedure on the claim is '21', which indicates the procedure was performed in an inpatient hospital. If there is no facility associated to the claim and the services indicate as being performed in an inpatient hospital, this validation will catch that based the lack of a facility name. The Place of Service Code value appears in the claim details under Procedure > Specific Procedure Code > Place of Service Code.

The Place of Service Code value in the claim details pulls from the Place of Service drop-down in the charge window of the patient's ledger.


Facility > Admission Date

The Admission Date will pull to the claim if a facility is associated to the charges on the claim and an Admission Date has been entered into the charge window for one of the procedures. 

If the Place of Service Code in the claim details is '21', which means Inpatient Hospital, for any of the charges on the claim, an Admission Date is required, otherwise the claim will move to the Invalid bin.

The Place of Service Code value in the claim details pulls from the Place of Service drop-down in the charge window of the patient's ledger.


Facility > Address Line 1


This field will pull to the claim if the same facility reference is tied to each charge on the claim. The facility is added to the charges by selecting it in the charge window for the procedures on the claim. If the same facility is tied to each charge on the claim, Facility > Address Line 1 will pull from the record in References > Facility.

Facility > National Provider ID


This field will pull to the claim if the same facility reference is tied to each charge on the claim. The facility is added to the charges by selecting it in the charge window for the procedures on the claim. If the same facility is tied to each charge on the claim, Facility > National Provider ID will pull from the record in References > Facility.

Procedure
Procedure > Procedure Code


This item in the claim details does not have a label as the other fields do. Rather, this field is indicated by clicking on the triangle to the right of the 'Procedure' node. This will reveal the contents of that node. The visible contents of this node are the procedure codes that will appear on the eClaim. The procedure codes themselves can then be twisted down to reveal the information that is specific to each procedure code.

The Procedure Code pulls into the claim details from the Code field of the charge window in the patient's ledger.

Since there is no way to produce an eClaim in MacPractice without having procedures on the claim, it will be nearly impossible for a claim to move to Invalid for missing procedure codes. However, if a claim ever does move to Invalid for such reasons, this is where the problem will be indicated.

Procedure > Procedure Code > Fee


As with the procedure code, it is nearly impossible to create a claim without a procedure fee. MacPractice will not allow the user to save a charge that does not have a fee assigned to it. However, if a claim ever does move to Invalid for such a reason, this is where the problem will be indicated.

Fee pulls into the claim details from the Total Fee field of the charge window in the patient's ledger.

Keep in mind that a $0.00 fee is not the same as no fee amount. $0.00 is a valid charge amount in many cases. It is also a valid payment amount offered by payers in many cases. Therefore, eClaims should never move to Invalid for $0.00 fee amounts.

Procedure > Procedure Code > Service Date


It is nearly impossible to create a claim without a procedure service date. MacPractice will not allow the user to save a charge that does not have a procedure date entered. However, if a claim ever does move to Invalid for such a reason, this is where the problem will be indicated.

Service Date pulls from the Procedure Date field of the charge window in the patient's ledger.

Procedure > Procedure Code > Unit


MacPractice will not allow the user to save a charge that does not have a procedure units entered. However, if a claim ever does move to Invalid for such a reason, this is where the problem will be indicated.

Units pulls from the Units field of the charge window in the patient's ledger.

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