FAQ Medical Claims Clearinghouse Software
What should we look for in a Medical Claim Clearinghouse?
Your first step should be to identify your top 15-20 health care insurance carriers you submit medical claims to and make sure these health insurance carriers are on the medical claims clearinghouse software list. Not all health insurance carriers are setup to accept electronic medical claims so place a call with those insurance carriers and identify their method of accepting medical claims.
The next step would be to identify the number of patients a day you treat, the number of medical claims generated from those patients and identify the number of medical claims you will be submitting to the medical claims clearinghouse electronically. Here is an example:
Doctor A treats on average 23 patients a day and creates 23 medical claims.
Averages:
- 10 patients Blue Cross
- 5 patients United Health Care
- 3 patients Aetna Health Insurance
- 2 patient Cigna
- 3 patients Self Pay
With these #'s we can assume that on average 20-25 claims will be going electronically to Blue Cross, UHC, Cigna and Aetna Health Insurance carriers. Some medical claim clearinghouses will charge you a per insurance claim service. In this case it would be 20 claims x 20 days (average # of days the doctor works a month) = 400 claims you will be submitting to the medical claims clearinghouse. When you begin reviewing pricing you will have an idea of the top health insurance carriers you submit to along with the average # of claims you plan on submitting to the medical claims clearinghouse each month.
Additional services like online eligibility, claim status, Remittance Advice, and Reports are offered by medical claim clearinghouses. Talk with your medical providers to see if these are services your medical office is interested in using. If the answer is yes, you will want to find a medical claim clearinghouse that offers these additional services or work with your practice management software to see if they offer these services.
Medical Claims Clearinghouse List options?
Normally when reviewing the claim clearinghouses website they will show you a list of their insurance carrier payers they are connected with. Compare this list with your health insurance carriers you submit claims to.
Medical Clearinghouse Upload File types/extensions?
- Print Image File (PIF)
- National Standard format (NSF)
- American National Standards Institute (Ansi 837)
Glossary of medical clearinghouse terms?
ERA or Electronic Remittance Advice: Notification of what they payor will pay on the claim which is the same information you would receive from your EOB or Explanation of Benefits.
NSF or National Standard Format: The NSF is a guideline for building electronic claims which consists of fixed-length (320 bytes) records.
PIF or Print Image Format: It is a completed CMS 1500 form without the form or background of the medical claim template.
ANSII 837 Format: HIPAA compliant version of the Professional medical claim (CMS-1500) which has many format options.
Par or Participating Claims: Normally it means the provider or medical facility is credentialed with a particular health plan. When claims are submitted electronically through a clearinghouse for participating insurance carriers that clearinghouse gets reimbursed a fee per claim from the payer.
Non Par or Non Participating Claims: Normally it means the medical provider or medical facility is NOT credentialed with the insurance carrier and the medical clearinghouse does not get reimbursed for submitting claims electronically to them.
Claims Acknowledgment Report: A report that reflects all medical claims submitted. This report has an identifier to indicate those that passed the medical clearinghouses edits and were forwarded on to the insurance carrier and those that were denied will be found in your exclusion report with exclusion reasons.
Claims Exclusion Report: Medical claims that have been excluded along with the denial reasons. These will need to be fixed and rebilled electronically or dropped to a paper claim depending on the issue.
Practice Management System: A medical database to store patient demographics, schedule appointments, post charges and payments while identifying the status of any outstanding balances. For practice management software products that offer document and image storage you can retain chart information in your database like medical records, licenses, patient photos, insurance cards, and patient registration forms.
DME or Durable Medical Equipment: Check with your medical clearinghouse to confirm they submit claims electronically for Durable Medical Equipment.
Eligibility Verification: Confirm if a patient is eligible for medical insurance benefits while identifying what copayment's, deductibles and co-insurance amounts are due.
Medical Electronic Statement Processing: stop printing and stuffing patient statements in your office and outsource this to clearinghouses to perform.
What types of services do Medical Claim Clearinghouses provide?
- Online Patient Eligibility and Address verification
- Electronic Medical Claim Submission
- Medical Paper claims submitted by the medical clearinghouse
- Electronic Remittance Advice
- Real Time medical claim status
- Patient medical statements and Collection Letters
- Patient Portal to pay medical bills
Additional Medical Claim Clearinghouses Articles for detailed information?
What is a Medical Claim Clearinghouse
How to read Clearinghouse EDI Reports
Why use a Clearinghouse
Is it possible to find a perfect Medical Billing Software and medical claims clearinghouse solution?
Yes. But remember what may be perfect for one medical practice may be horrible for another practice. Medical software, Medical Clearinghouse and Medical EHR/EMR software vendors are constantly improving their medical software with weekly, monthly, quarterly enhancement releases to wow YOU the doctor and retain your business because they know you have choices. Yes, It is possible to find a great medical billing software, medical clearinghouse and medical EHR/EMR solutions today.
Why use medical billing software pro's website?
After many years of consulting doctors it seemed like we kept getting the question, "is there anything better?" Well, we hope to answer that question through this website.
This website was specifically created for medical doctors and office staff to gain the knowledge needed prior to making the phone call to the medical practice management and claims clearinghouse software vendor(s).
Our hope is that this Medical Website gives you the power you need to make the right decision for your medical practice. You have some wonderful medical billing and claims clearinghouse software vendors to choose from and we wish you the very best in your decision to find that perfect medical software.
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