This document outlines procedure to download Electronic Remittance Advice(ERA) from Optum and applying payments to claims.
Electronic Remittance Advice(ERA) is an electronic form of claim payment information from payer with explanation of benefits(EOB) details.
ERA can be downloaded in two ways. 1) Manual download 2)Automatic Download, where download frequency and time of download can be configured by the practice.
Manual Download option, 'Download ERA' is available under 'Billing ~> ERAs' tab.
Clicking the 'Download ERA' option opens the 'ERA Download' dialog. Choosing the date period and clicking 'Download ERA' button connects to the Optum server and downloads available ERAs in the selected time period. Once the ERAs are downloaded a brief summary of downloaded files is shown.
One can avoid this routine manual ERA download process and automate ERA download. Under 'Settings ~> eClaims ~> ERA Settings' ERA download can be configured with frequency and time of download.
ERA download transactions are listed under 'Billing ~> ERAs ~> ERA Download History'.
Downloaded ERAs can be viewed in 'Billing ~> ERAs' tab. List of ERAs can be seen with details such as date, payer name, payee name, check/EFT number, check/EFT date.
A brief summary of the over all ERAs downloaded is shown at the top of the ERA list view with numbers of ERAs, EOBs, Mapped and Unmapped EOBs, Successful Payment and Payment failures.
|Mapped EOBs||EOBs having claims in ChARM. These EOBs can be viewed against the claims in 'Claims' tab.|
|Unmapped EOBs||EOBs for which ChARM could not find matching claims. It means that either the claim is not created in ChARM but submitted from some other system or the claims available in ChARM but our standard algorithm is failed to find it.|
|Successful Payment||EOBs for which claim payments are successfully applied.|
|Payment failures||EOBs for which applying claim payments failed. Practice can apply these payments manually.|
Click on an ERA from the list to see the detailed view of that ERA. This view shows the following information.
To find a matching claim of an EOB, ChARM uses the following detail from that EOB, such as Patient Control Number, Date of Service and 1st CPT in EOB and searches for the claim. When the EOB is mapped with a claim, the respective Invoice ID is shown above that EOB.
Sometimes ChARM may fail to identify the claim of an EOB. This means, either the claim for that EOB is created and submitted from some other system or the logic used for claim mapping fails to identify the claim. In such case an error message is displayed above the EOB. Refer the below screenshot.
If the actual claim is created in ChARM then user can find the claim and map it to the EOB using the option "Select the claim for this EOB". Clicking this option shows a dialog with a list of claims matching the patient name in that EOB. User can verify the list, select the particular claim and map it by clicking 'Match Claims' button.
If there is no claim in ChARM for the EOB received, it can be marked as EOB with no matching claim, using the option "Do not show this message. This EOB does not have a matching claim".
If claim is mapped with EOB and there is error in applying paymnet automatically, a message is displayed with the reason for failure. In such case user has to manually apply the payments. Once the payments are applied, one can clear this error by clicking "Do not show this message again, Payment was manually applied".
EOBs mapped to claim can be viewed against the claim by clicking 'Show EOB' button which can be printed and exported as PDF as shown below. If a claim has multiple EOBs it can be viewed by selecting the drop down on the top left.
Automatic claim mapping and payment posting can be controlled through ERA Settings. All the options available in ERA settings screen are explained below.
|Map EOB with Claim||'Yes' is selected by default, which maps the EOB with its claim in the ChARM. On selecting 'No' EOBs are just downloaded and listed.|
|Apply Payments in EOB to the claim||'Yes' is selected by default, which applies payment to the claim automatically. When 'No' is selected, claim payments would not be applied. This option should be chosen when practice wants to add payments manually.|
|If EOB has Reversal payments, then||'Do Nothing' is selected by default, which will not apply any payment when there is an EOB with negative payment.|
|If any CPT line in EOB has Zero Payment without CoPay, CoInsurance and Deductible, then||'Mark CPT as Denied' is selected by default which marks the CPT line as denied if it has zero payment without Patient Responsibility types like CoPay, CoInsurance and Deductible. If 'Apply values as given in EOB' is selected a payment amount of zero is added for the CPT.|
|If any CPT line in EOB has Patient Responsibility other than CoPay, CoInsurance and Deductible, then||'Apply it as Patient Responsibility Not Covered' is selected by default, which marks Patient Responsibility other than CoPay, CoInsurance and Deductible as Not Covered. Select 'Do Nothing' if the above action is not required.|
|If any CPT line in EOB has "Other Adjustment", then If any CPT line in EOB has "Payer Initiated Adjustment", then||'Apply it as Adjustment Provider Adjustment' is selected by default, which marks Other Adjustment or Payer Initiated Adjustment in EOB as adjustment with type Contractual Obligations. Select 'Do Nothing' if above action is not required.|
EOB from Payer gives payment, adjustment and patient responsibility details for each line item in the claim. It is also possible that one CPT in a claim gets paid where as the other CPT gets denied.
It is recommended to enable line item level payments and get the payment & denial information from payer for individual CPT. To enable line item level payments go to 'Settings -> Billing -> Billing Settings' and select 'Yes' for 'Enable Item Level Payments for Invoices' option.
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.
Navigate to Settings > Facility > Roles to grant or revoke permissions.
What does the error message 'Unable to connect to Optum servers. Timeout occured' indicates?
To download ERAs, ChARM tries to establish connection with OPTUM. Some times due to some network issues ChARM may not be establish the connection with OPTUM and this error is being shown. In such cases practice should try the download after some time.
What does the error message 'Unable to read the ERA from the Optum servers. Timeout occured' means?
Even after ChARM establishes connection with OPTUM servers, sometimes ERA download may fail due to some error with OPTUM network. In such cases, practice can try this option after sometime.
in automatic download, when we cannot get ERAs from Optum, subsequent attempt will download ERAs from the last successful downloaded date.
Note: When practice has multiple facilities and each facility is using different Optum account, ERA scheduler has to be configired for each facility.