Electronic Remittance Advice (ERA) Processor

Transcription

1 Electronic Remittance Advice (ERA) Processor Users Guide Brief description of the Electronic Remittance Advice (835) or Electronic EOB A Remittance Advice (RA) is a notice of payments and adjustments sent to providers, billers, and suppliers. After a claim has been received and processed, a Payer (anyone who pays medical claims) contractor produces the RA, which may serve as a companion to a claim payment(s) or as an explanation when there is no payment. The RA explains the reimbursement decisions including the reasons for payments and adjustments of processed claims. Benefits of using Electronic Remittance Advice (835) More detail EOB information Paper less remittance advice Quicker payment notification Automatic payment into Accounting System (Reconciliation) Identify problems(adjustments, denials, pends and others) instantly associated with claims and payments Electronic Remittance Advice (ERA) Processor Professional The Electronic Remittance Advice (ERA) Processor Professional is the professional version of the ERA, which allows the following functions: Generate a flat file Generate a PDF of the ERA(835) Display the content of the ERA on the screen Generate a CSV file in a user-friendly format for ease of read and quick analysis. For custom CSV format contact

2 Figure 1 Menu Item Generate Flat File Generating a flat file this option allows you to select an ERA ( ) EDI file and dump the output in an easier readable format. Please note the EDI file have to delimit in the sense that the individual EDI segment need to be on its own separate line. The file cannot be one continuous line. If the file is one continuous line; the file needs to be delimited by EDI segment. There are several Tools available on the internet to perform this function. Alternatively, you can buy a copy of a EDI delimiter at for approximately $10, that will delimits any EDI file into its individual EDI segments. When the Generate Flat File is completed, you will see a popup that will let you know how many claims the Tool processed. The output file will be located in the same location as the file that was selected for processing. Two file will be produced by the process: 1) File name Output835_YYYYMMDDhhMMss.txt where for example OutPut835_ txt YYYY Year MM- Moth

3 DD Day of month HH Hour MM Minutes of the hour SS - Seconds 2) File name Output835_Error_YYYYMMDDhhMMss.txt The output error file contains processing errors if any error occurs during processing. Menu Item Generate PDF Generate a PDF this option generates a PDF of the file that was selected. The output file will be located in the same location as the file that was selected for processing. Two file will be produced by the process: 1) File name Output835_YYYYMMDDhhMMss.pdf 2) File name Output835_Error_YYYYMMDDhhMMss.txt Contains error if any error occurs during processing. Menu Item Display RA The Electronic Remittance Advice (835) processor converts an Electronic Remittance Advice (835) into a flat file, or display on the screen so that the important pieces of information associated with payment can be easily read. One of the advantages of an electronic version of the EOB is speed. The status of a submitted claim is extreme important, the Electronic Remittance Advice lets you know the status (Paid, Denied, Pended or Other) of a claim. If the claim was denied for whatever reason the user do not have to wait for weeks for the paper EOB to arrive to your office in the mail, the user pull it up on the screen and see each individual check on the screen then click on the claims for a particular check. Displayed on the screen are three separate buckets (Paid, Denied or Pended/Other).

4 Figure 2 Electronic Remittance Advice(ERA) selection screen Select input Remittance Advice (835) file. Please note the file needs to be broken down into the individual segment. A message will pop up if file is not segmented. Figure 3 Invalid ERA file selected The following message wills popup when the Remittance Advice (835) is completed letting you know how many remittance advice records have been processed. For example, the number 14 at the end of the message represent the actual number of records.

5 Figure 4 Number of records processed The output of the Remittance Advice file that was processed can be found in the directory where the input file has been selected. The example below is from a previous run. Output835_ txt Output835_Error_ txt The format of the output file is Output835_yyyyMMddHHMMss.txt (Year, Month, Hour, Minutes, and Seconds) Output835_Error_ contains any error that may have occurred and the number of record processed. 1. Click button Select 835 Figure 5 Display ERA main screen

6 The following file browser screen will pop up and allow the user to browse to the directory on your PC where the input file is located. Figure 6 ERA file selection screen 2. Select the Remittance Advice you want to display

7 Figure 7 ERA Claims Header details Figure 7 display the check number, check amounts, and check date along with some other detail check summaries The screen is divided into two panes the top pane contain the Remittance Summary Information and the bottom pane contain Other Provider Adjustments The bottom pane contain any information on the PLB segment on the Electronic Remittance Advice. The amounts listed in this section relates to other provider expenses such as (Recovery Allowance, Interested Penalty Charges etc.) that may not be related to a claim on the current ERA. 3. Click on the line item in the table that relates to the claims associated with the check figure 7. The claims listed below are associated with the check from above. The default tab is the Paid Claims

8 Paid Claims Tab Please note the numbers on each tab represent the number of claims that falls within that bucket. There are three buckets (paid, denied, pend\other) represented. Figure 8 Paid Claims Tab 3. Click on one of the line item in the table to see the detail or service lines associated with the claim

9 Figure 9 Paid Claims Tab details Figure 9 shows the service detail line item of the charges associated with a claim; include all adjustments if there are any. Figure 10 show all of the claims associated with a particular check that have Denied for whatever reason.

10 Please Note you will see in the table column name Claim Status you will also see claim here that have been processed as a Paid claims. The reason why they are listed here is that one or more of the service line have been denied for whatever reason. Denied Claims Tab Figure 10 Denied Claims Tab

11 Figure 11 Denied Claims Tab Details When the user click on one of the rows of a claim in the table the detail service level shows up in red to let the user know there was a problem with this particular claim. Pend\Other Claims Tab The Pend\Other tab shows all claims that have pended or other claims statuses that do not fit into the denied or paid bucket.

12 Figure 12 Pend/Other Tab Figure 13 shows all other claims that has not denied or paid. From the example the Pend\Other claims bucket shows the claims status of Reversal of a Previous Payment. This status represents claims that have been corrected and resubmitted for payment. The text also shows up in red to focus the users attention.

13 Figure 13 Pend/Other Tab details The Remittance Advice program allows you to open up not only one file but multiple Remittance Advice files by going back remittance advice selection screen in figure 5 and just selecting another file. When the user selects a new file the user will notice that a new line will appear in Remittance Advice Transaction Summary

14 Menu Item Generate CSV Generate a CSV (Comma separated Value) this options generates a CSV file. The output file will be located in the same location as the file that was selected for processing. Two file will be produced by the process: 1) File name Output835_YYYYMMDDhhMMss.csv 2) File name Output835_Error_YYYYMMDDhhMMss.txt Contains error if any error occurs during processing. This option can be used to import the ERA(835) information into a database for further processing, open the file directly in Microsoft Excel or import the ERA directly into your internal billing system. File Layout of CSV file generated from ERA Record Name REC01 (File Header Information) Process date Total Check Amount Check Date Check Reference Date Payer Process Check Payer Name Payee(You) Name Record Name REC02 (Patient Header Information) Random Generated Identification Record Count Patient Account Number Claims Status Total Provider Charge Total Payer Paid

15 Payer Assigned Claim Identification Patient Last Name Patient First Name Patient Identification Number Rendering Provider Rendering Provider Tax Identification Date Payer Received Claim Record Name REC03 (Claims Detail Information Service Line Level) Random Generated Identification Record Count Procedure Code Amount Provider Charge Amount Payer Paid Date Service Started Date Service Ended Record Name REC04 (Claims Detail Information Service Line Level) Random Generated Identification Record Count Claims Adjustment Group Code Claim Adjustment Description Claim Adjustment Difference Amount Record Name REC05 (PLB Segments) File Level Information Other Provider Adjustment Reference Number Other Provider Adjustment Reference Number Reason Number

16 Other Provider Adjustment Amount Record occurrence per CSV file Record 01(REC01) can occurs 1 time per file Record 02(REC02) can occurs 1 time per claim multiple times per file Record 03(REC03) - can occur multiple times per claims dependent on the number of service line per claims Record 04(REC04) - can occur multiple times per claims service line Record 05 (REC05) can occur multiple time per file