EMR/EHR claims submissions can raise a lot of questions, so I’ve answered five of the most common questions below.
As an example, I’ve used Champ Software’s EHR/EMR, Nightingale Notes.
In Nightingale Notes, you can create an electronic claim, so if there are any missing pieces of data at the time of the claim generation, Nightingale Notes will give you validation errors, and will not create the claim until the missing data is supplied.
What do I do with the claim once I’ve created it?
You know that the claim needs to be sent to the payer, so that they can make payment for the clients’ services.
Before the claim can be paid, it has to be checked to make sure it contains the correct information, such as client identification, as well as correct procedure codes, diagnoses, etc.
This is called claim scrubbing. It will be scrubbed, may be returned for correction of any errors found in the scrubbing process, and ultimately it will be paid.
When do I submit claims directly to the payer?
Some larger payers, such as large insurance companies and state Medicaid systems may have their own web portals, where you would upload your claims directly to the payer.
A web portal is a secure, HIPAA compliant website that you can log into and then upload your claim files, as well as view claim rejections and receive remittance advice back. This is usually free to the billing provider.
They would scrub and review the claims, and then send payment back to you.
When do I submit claims to a clearinghouse?
When other payers do not have their own web portals, and you must rely on a ‘middle man’ to scrub the claims and then transmit them to the payer for payment. This is a clearinghouse.
Sometimes these payers work with a specific clearinghouse, or a few different clearinghouses, and you can usually find this information by going to the payer website.
Clearinghouses frequently offer other services, as well such as:
- Eligibility checking
- Electronic remittance
Some clearinghouses perform their services for free to the billing provider, and receive payment from the payer.
Other clearinghouses charge a fee up front.
How do I determine which clearinghouse my payer works with?
It’s mentioned above that you may find which clearinghouse your payer works with by finding the information on the payer’s website.
You can also check on a clearinghouse website for the payers they work with.
They usually have a ‘payer list’ or ‘health plan partners’ list which contains all of the payers they work with, and may also give you some other information, like whether they scrub claims, provide eligibility or remittances, and if there is a charge for their services.
How do I determine which clearinghouse to work with, if I have options?
Check with some to determine if they would be a good fit for you:
- Are they free or affordable to you?
- Do they offer good training and support, during the learning process and later as you are submitting claims?
- Is the software easy to use?
- Do they offer other services you may wish to use, such as eligibility checking?
Here is a short list of clearinghouses that some of our Champ Software Nightingale Notes customers use:
- Gateway EDI: Champ Software has a partnership with Gateway EDI, so if you use their services and let them know you are a Nightingale Notes user, you will receive a discount
- Availity: Many of Champ Software’s customers use Availity. Most of the claims that you would submit would be free to you. However, there is a charge for submitting claims to some of the government payers
- ClaimShuttle: Champ Software’s understanding is that this is a low cost service
- Office Ally
There are also many other clearinghouses which you can find by searching on the internet.