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eClaims - How Does an Institutional eClaim End Up In The Invalid Bin?

Institutional eClaim Validation (Including UB-92_Capario 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.
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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.

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


The 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 > 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: 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:


Provider > Physical Address Line 1 (Special Circumstance)
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.

Provider > Physical Address City (Special Circumstance)
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.

Provider > Physical Address State (Special Circumstance)
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.

Provider > Physical Address Zip Code (Special Circumstance)
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 > Type of Bill


This information is located in References > Offices in the field for Type of Bill.

Patient
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 > 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.

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.

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 > 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 > 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 > 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 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, the value will pull from the Plans tab > Demographic sub-tab > Zip Code field.

Primary > Payer Identification Number


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.

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


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.

Procedure
Procedure > Service Date


This information pulls from the Procedure Date field, located within the charge window, accessed from the patient ledger within the Patients Ability. Double-clicking the procedure from the ledger will display the charge window.

Procedure > Code


This information pulls from the Code field, located within the charge window, accessed from the patient ledger within the Patients Ability. Double-clicking the procedure from the ledger will display the charge window.

Procedure > Revenue Code


Procedure > Revenue code pulls from the fee schedule reference, from the revenue code field of the selected procedure, within the selected fee schedule.

Procedure > Fee


This information pulls from the Unit Fee field, located within the charge window, accessed from the patient ledger within the Patients Ability. Double-clicking the procedure from the ledger will display the charge window.

Procedure > Units


This information pulls from the Units field, located within the charge window, accessed from the patent ledger within the Patients Ability. Double-clicking the procedure from the ledger will display the charge window.

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