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Electronic Claims

Electronic Claim Submission

This document outlines the procedure for Electronic Claim Submission and downloading Electronic Remittance Advice (ERA). ChARM EHR uses Optum clearing house to submit claims. Practice should sign up with Optum to use these features.

Electronic Claim Submission

Claims generated for charts can be submitted to Optum from ChARM EHR by a click of a button without logging into Optum. Option to test claims for errors and 'Advanced Clinical Edits' (ACE) is provided. It is recommended to test submit claims before submitting them to payer. Upon successful claim submission, status of the claims will be changed to 'Submitted Electronically'. ACE errors are the warning messages Optum shows based on the details in the claim.

Submitting Claims Electronically

Clicking on 'eClaim Submission' button under 'Billing ~> Claims' tab, lists all the claims ready for submission.
eClaim Submission Option

Multiple claims can be selected and submitted from the list by clicking on 'Submit For Testing', 'Check ACE and Submit' or 'Submit To Payers'. On submitting the claims, ChARM validates the claim detail and prompts for any missing or invalid information in the claim. Section 2.3 Data Validation Prior to Claim Submission explains more on this validation.
eClaim Submission View

i) Submit For Testing
This can be used to test claims for errors and Advanced Clinical Edit (ACE) warnings before submitting claims to payer. Optum's 'Advanced Clinical Edits' is used to identify and correct coding errors prior to sending the claims to payer. This will help in reducing the denials from the payer for certain errors that are captured by OPTUM before sending it to the payer. The warnings are shown to the user and claims are not submitted to payers.

ii) Check ACE and Submit
Claims are submitted to payers if there are no errors and ACE warnings. Claims with errors and ACE warnings are not submitted and details of the errors and ACE warning are shown in the response. We change status to 'Submitted Electronically' if the claim submission is successful. Else status is changed to 'eClaim Rejected by Optum'.

iii) Submit To Payers
After reviewing ACE warnings, if it is okay to submit the claims ignoring these ACE warnings, this option should be used. Claims are not checked for ACE warnings and those which do not have any errors are submitted to payers. We change status to 'Submitted Electronically' if the claim submission is successful. Else status is changed to 'eClaim Rejected by Optum'.

Claim submission response shows summary of claims Accepted and Rejected. Claims rejected will have details of Errors and ACE warnings.
eClaim Submission Response

'Claim submission is successful' indicates that the claim is transmitted to the clearing house, OPTUM successfully. OPTUM will inturn submit these claims to payers periodically. Sometimes payers will reject the claim if there is some issue with the claim details such as patient insurance id. So the best practices is check & track the claim status periodically. Claims status can be verified in OPTUM's ENS Health portal. Refer Section:3 Tracking Claims Status ENS Health Portal of this document for detailed instruction of checking the claim status and tracking. When the claim is rejected, claim details should be changed based on the rejection comments and claim should be resubmitted.

Submission History

Click 'eClaim Submission History' button in 'Billing ~> Claims' to view past transactions of submitted claims. Response details can be seen by clicking 'View' as shown below. Claims submitted for testing, using 'Submit For Tesing' are not shown here in the history.
eClaim Submission History

Submission response can also be viewed against the claim by clicking 'eClaim Transactions' button as shown below.
eClaim Transactions

Data Validation Prior To Claim Submission

When a claim is submitted to clearing house it will be rejected if it has missing data or it contains invalid data as per ANSI 5010 specification. To avoid this, on submitting claims ChARM validates the claim information before submitting them to clearing house. Claims with any missing/invalid data will not be submitted to the clearinghouse and the relevant errors will be shown. And other claims without any issues will be sent to the clearinghouse.

ChARM validates for the following information

  • Submitter(consulting provider/service facility) Details
  • Billing Provider Details
  • Subscriber Details
  • Payer Details
  • Patient Details
  • Other Claim Details

eClaim Validation Error

 

Below is the list of possible error messages with a brief description for each error. Procedure for correcting these errors is also given.

Claim Submitter Detail is mandatory. Select the Submitter.
Submitter is either provider of the practice or facility. By default, consulting provider of the encounter is selected as Submitter. This can be changed in the last step (eClaim Detail) of the claim wizard.

Submitter contact information is required. Provide at least one of the contact details given below
1. Phone Number    2. Fax    3. Email
Submitter contact detail is mandatory as per ANSI 5010 specification. If submitter is a provider, go to 'Settings ~> Facility Members' in settings, edit the respective provider, and provide Phone Number, Fax or email of the provider. If the submitter selected is a facility, go to 'Settings ~> Facility List' in settings, edit that facility and update the contact information. Now edit the claim, reselect the submitter in the last step of the claim wizard, and save the claim.

Enter 9 digit ZIP code for Billing Provider
ZIP code must be 9 digit (i.e, 5 digit ZIP and 4 digit Postal Code) for Billing Provider and Service Facility. Go to 'Settings ~> Billing Provider', edit the 'Billing Provider' and update the ZIP and postal code. Then edit the claim and reselect the billing provider in the 3rd step of the claim wizard and save the claim.

Billing Provider Identifier is required. Enter any of the following Identifiers
1. NPI    2. State License Number    (0B) 3. Provider UPIN Number (1G)
Provider Identifier is mandatory for Billing Provider. Edit this 'Billing Provider' under 'Settings ~> Billing Provider', and update it with NPI. Then edit the claim and reselect the billing provider in 3rd step of the claim wizard and save the claim.

Primary Insurance Payer ID is missing. Enter the Payer ID
Payer ID is mandatory for electronic claim submission. To add 'Payer ID' of the insurance payer, edit the claim, update the Payer ID using 'Edit Insurance Details' link against the primary insurance and save the claim.

Rendering Provider Identifier is required. Enter any of the following Identifiers
1. NPI    2. State License Number (0B)    3. Provider UPIN Number (1G)    4. Provider Commercial Number (G2)    5. Location Number (LU)
Provider Identifier is mandatory. Edit the provider under 'Settings ~> Practice Members' and update the NPI. Then edit the claim and reselect the rendering provider in 3rd step of the claim wizard.

Enter 9 digit ZIP code for Service Facility
Service Facility must have 9 digit ZIP code (i.e, 5 digit ZIP and 4 digit Postal Code) for electronic claim submission. Edit the facility under 'Settings ~> Facility List', update it with the ZIP and postal code. Then edit the claim and reselect the facility in the 3rd step of the claim wizard and save the claim.

Service Facility Identifier is required. Enter any of the following Identifiers
1. NPI    2. State License Number (0B)    3. Provider Commercial Number (G2)    4. Location Number (LU)
Identifier is mandatory for the Service Facility. Go to 'Settings ~> Facility List' and update it with the facility NPI. Then edit the claim and reselect the facility in 3rd step of the claim wizard and save the claim.

Select the "Policy Type Code" of Secondary Insurance [MEDICARE]
ANSI 5010 specification mandates for 'Policy Type Code' when MEDICARE is 'Secondary Insurance' in the claim. This can be selected in the last step (eClaim Detail) of the claim wizard.

Diagnosis Codes related to this service (24.E) are not specified. Select the Related Diagnosis Codes
This is shown when Dx codes are not mapped to a CPT. To correct this, edit claim, edit the respective CPT in 2nd step (Procedures and Dx) of the claim wizard, update it with mapping Dx codes and save the claim.

Tracking Claim Status ENS Health Portal

Once the claims are submitted user can check and track the status of the claim in ENS Health Portal. Connect to the portal at http://www.enshealth.com, and login with your portal account. You can check reports in 'Message Center' to track claim status. You can also verify a particular patient's claim status using Electronic Claims Tracking(ECT).
eClaims Tracking

Message Center

This lists all the reports which contains the claims recent status detail such as, whether claim is submitted to OPTUM, accepted by Payer, claim entered the adjudication system, claim is rejected, etc. By default all the unread reports are being shown in the message center. Selecting any particular report shows a list of claims with status. To generate a detailed report, select all entries and click on 'View Report'. This gives a detailed report with claims recent status.
eClaims Tracking
eClaims Tracking

Electronic Claims Tracking(ECT)

User can use the 'Advanced Search' in ECT and search for claims of a particular patient with Patient Account# or claims in a particular date period.
eClaims Tracking

Claim Resubmission

After checking the claim status, If the status is rejected then user have to check the respective rejection reason and do the required corrections in the claim then resubmit the claim.

Configure Role Based Access to eClaim Submission

Access to ERA and eClaim submission are given to PracticeAdmin and Biller roles by default. These permissions can also be given to other users using Role Based Access in EHR.

eClaim P ermissions

  • Export (PDF to print on CMS1500 form, PIF for Optum) For allowing member to submit claims to Optum.
    eClaim Access Settings