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EDI Unleashed – Series 4

Supriya Sonavane Dec 18, 2012

Electronic Claim Submission Electronic Data Interchange Healthcare EDI Healthcare EDI Technology ClearingHouse

In the previous blog we discussed about the concept of Clearinghouse. With the advent of Electronic Claim Submission, there are n numbers of Clearinghouses in the market today with each offering diverse range of services.

Clearinghouses can undoubtedly make the process of claim submission very smooth provided the one which best meets the needs of a provider is selected.

So the question is how to decide which Clearinghouse is best? That’s what we shall address in this blog.

Criteria to select Clearinghouse:

The best Clearinghouses offer added features that provide a whole new level of claim intelligence that makes their services extremely compelling from a financial perspective, along with being highly desirable from an office-staff efficiency point of view.

Here are some highlights on what to look for in premium services:

  • Eligibility verification: Determine coverage before treatment.
  • Electronic remittance: Have your accounting automatically updated.
  • Claim status reports: Know the status of a claim at all times.
  • Rejection analysis: Have error codes displayed in plain English.
  • Online access: Edit and correct claims day or night online.
  • Printed claims: Have non-par claims automatically dropped to paper but still be able to track them electronically.
  • Patient statement services: Have patient statements put on ‘autopilot’, often at less cost than you can mail them out yourself.
  • Real support: The best clearing houses offer one-on-one personal training and support provided by billing experts.
  • Affordability: When provider takes into consideration the purchasing of forms, printing, envelopes, and postage; a clearinghouse ends up costing about the same as sending paper claims.
  • Payer list: First and foremost, make sure that the insurances provider bill on a regular basis are on their payer list. This list is most often available online at their website.
  • Nationwide: many Clearinghouses are regional. Steer towards ones that operate nationally.
  • Office software: Evaluate if the Clearinghouse is compatible with the billing software used in clinics. This part can make a tremendous difference to avoid what billers know as clearinghouse hell.
  • Easy-out contract: Most of the better services today offer a month to month subscription.
  • Support: Evaluate Clearinghouse support before signing up.
  • Error reports & Control panel: Most Clearinghouses will offer a quick tour of their control panel (the location online where claims will be managed). What providers want here is easy navigation within the management area, and claim errors and rejections to be reported in clear, concise language, not merely as numbers which can be extremely confusing.
  • Monthly fees: Many of the best Clearinghouses charge between $85 and $125 per month, per doctor (rendering provider in box 24-J). The ones that charge more are not necessarily worth the extra cost.
  • Advanced features: Over and above just transmitting electronic claims, the best medical Clearinghouses offer many highly desirable advanced features such as: Eligibility Verification, Sent File Status, Claim Status Reports, Rejection Analysis, Paper Claims (created for you and mailed when necessary), Secondary Claims Processing, Electronic Remittance Advice (ERA), Patient Statement Services (you no longer have to mail out all those patient statements each month), Payment Processing, and finally, Transaction Summaries of all your clearinghouse activity. These advanced features make a good clearinghouse worth its weight in gold.

We are now much more conversant with various aspects of EDI messages.

In the next blog we will look into the details of EDI Claims messages and SDK’s available for generating them.

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