ERA User Guide
This user guide describes how to process electronic remittance advices (ERAs). In the healthcare industry, the terms electronic remittance advice (ERA) and electronic remittance notification (ERN) are used interchangeably. They both refer to a text file formatted using the X12 835 standard as mandated by HIPAA. Throughout Insight, including this document, the acronym ERA is used.
Before you can process ERA files in Insight Billing, enrollments for ERA must be completed with your payers. If you use a trading partner, you may need to go through the trading partner enrollment process. If you send claims direct to payers, you will need to enroll directly with payers.ERA1
To process ERA files, you must set up locations for storing the ERA files you download from trading partnersand for the archive files that Insight creates from the ERA files (called the archive folder). Setting up both of these locations is described in this section. In most cases, these locations are already set up. If so, you can skip this section.
Setting Up the Location for ERA Files
You can specify where ERA files are located. Once you set up this location, you can place ERA files you download into this folder. When you begin processing ERA files (as explained in Process ERA Files), Insight initially looks in this location for ERA files to process.
- Select Company & Clinic Info from the Settings menu. The Company Info and Clinic Management dialog box displays.
- In the ERA File Location drop-down list, select the folder where ERA files are located.
- Click the Close button to save and close the Company Info and Clinic Management dialog box.
You must specify where Insight places the archive files it creates from the ERA files you download from trading partners (Clinicient Billing Services uses Waystar (formerly Zirmed) as a trading partner).
- From the Utilities menu, select Master Files and then Trading Partners.
- Select a trading partner from the drop-down list at the top of the dialog box (Clinicient Billing Services should select Zirmed), or click the Add button to begin adding a new trading partner. Need to add specifics to guide through setting up a new trading partner here.
- In the File Information area in the lower-left of the dialog box, locate the Receive Path Name field. Click the button with three dots to browse to the folder that you want to contain the archive files.
- Click the Close button to close the Trading Partners dialog box.
Downloading ERA Files
Before you begin, you must download one or more ERA files from a trading partner (for Clinicient Billing Services, this is Waystar (formerly Zirmed)). Download the files into the folder designated for ERA files, as described in Set Up ERA File Location, earlier in this document. Clinicient Billing Service should check daily for ERA files and download them if they are available.
Receiving an EOB and Payment via ERA
Once you’ve downloaded and stored an ERA file, Insight can process it. When Insight does this, it creates payments and EOB entries based on information in the ERA file.
- Click the Payments tab and then click the EOB Posting tab.
- Click the Enter EOB by ERA button.
- In the Open dialog, select the ERA file to process, then click the Open button.
Note: You can select multiple files to process by pressing the SHIFT or CTRL keys while you select the files.
Insight loads and parses the file. A progress bar displays as each claim in the file is processed and placed in the archive folder, as set up in Setting Up the Location for the Archive Folder, earlier in this topic. If a file of the same name already exists in the archive folder, the new file is renamed by appending an underscore and time stamp to the file name. For example, ZIRMED1000.835 becomes ZIRMED1000_2008072214225.835.
Insight can process ERA files that come in a ZIP file. Typically ZIP files have a .ZIP extension. After processing a ZIP file, Insight places it in the archive directory. If there are multiple 835 files in the ZIP file, they are each processed and individually archived. When processing is complete, a message displays indicating the number of payments in the ERA file. For example, “This file contained 2 payments.”
Tip: Once you process an ERA file, it is removed from the directory where it was stored. The next time you click the Enter EOB by ERA button, that file isn’t listed in the Open dialog box. This makes it easy to work through downloaded ERA files—you always know which files are waiting to be processed.
If the ERA Number Cannot Be Found
If Insight cannot locate a payer with the ERA number in the ERA file, a dialog box displays that you use to select a payer and to assign the ERA number to the payer. The payer name as it appears in the ERA file is listed at the bottom of the dialog box, next to Payer Name in File.
All payers for the claims in the ERA file are listed under Payers in File. The number of claims for each payer is shown, and the payer with the most claims in the ERA file is listed first.
Note: If no claims can be identified in the file, the Payers in File grid does not display. In its place, No Identifiable Claims/Payers in this File displays.
- The payer with the most claims is selected under Select Payer to Assign to. Insight will assign the ERA number from the ERA file (shown in the Assign ERA number text box) to this payer. You can select a different payer by clicking on it in the Payers in File list.
- The Current ERA Number for the selected payer is shown. This lets you know if you are about to overwrite an existing ERA number for the selected payer. In no ERA number is set up for the payer, this says None. The ERA number from the ERA file is pre-entered in the Assign ERA Number text box.
- To see the selected payer’s ERA number, group, and address, expand the Select Payer to Assign to drop-down list.
- Click the OK button to assign the ERA number to the selected payer. ERA processing continues. If you do not want to assign ERA numbers at this time, click the Cancel button. No ERA number is assigned and file processing stops.
It’s possible that you receive both paper and electronic advices for the same payments. Insight checks for these duplicate payments and flags them as it’s processing the ERA file:
- If there is a payment in the system with the same payer, an exact match for the check number, and neither payment is for a zero amount, the payment is considered a duplicate. Processing for that ERA file is stopped and the ERA file is not loaded.
- If there is a payment in the system with the same payer, an exact match for the check number, and either payment is for a zero amount, the dialog box below displays and you can choose to continue or stop processing the ERA file.
- If the check number is not an exact match (sometimes paper and electronic advices use different formatting for the check number, such as one check number is 051777 and another check number is 51777), a similar dialog box displays the check numbers and amounts. You can choose to continue or stop processing the ERA file.
Payments and EOB entries
Each payment in the ERA file is entered as a check or electronic funds transfer (EFT), and includes the check issue date or the EFT effective date.
EOB entries are made. They display on the EOB Posting tab on the Payments tab. They are shown in the EOB Contents area. The Print ERA button prints a summary listing of all claims in the ERA file for the selected payment.
All charges that could be processed and applied are listed in the EOB Contents area. There may be times where you need to edit the information shown in this area, particularly if rows are shown in pink. Double-click on a row to open it in the Enter EOB dialog box where you can edit the amounts assigned to each category (Paid, Co-Ins, Denied, and so on).
Notice that the Unapplied Receipts tab is active, indicating there is a claim that couldn’t be identified and wasn’t applied. The section Handling Unapplied Receipts describes how to handle this situation.
Viewing Remittance Detail
You can view the detail for all remittances for a claim.
- Open the Enter EOB dialog box for the claim by double-clicking on the claim on the Payments tab (in the EOB Contents area, the Unapplied Receipts tab, or the Interest tab).
- Click the View ERA button on the Enter EOB dialog . This button is only visible for claims loaded from an ERA file.
The ERA detail viewer displays, as shown at right. It has a separate tab for each CLP loop in the claim. Some claims, such as take backs, may have multiple tabs for a single claim. The tabs are labeled with the payment date and ID. If there are multiple advices for the same claim in the file, they are numbered according to their position in the file.
Insight may not be able to identify claims in an ERA file. For example, a claim in an ERA file may say the number is 3695, but the full claim number in Insight is actually 30863695. Or a claim in an ERA file may say that a patient’s name is Fred, but Insight has the name recorded as Frederick. In these cases, you must manually match ERA claims to claims in Insight.
Insight lists claims it cannot identify on the Unapplied Receipts tab. This tab is only present if a payment is entered from an ERA file and there are claims Insight cannot identify. It shows a Reason the system could not identify the claim. You can edit this field—just type in the field. Your entry is automatically saved.
You must handle unapplied receipts manually. To do this, you double-click on a claim, as described in the next steps.
Tip: Click the Print ERA button to create a paper-based ERA. This may help you trouble-shoot unapplied receipts.
- To open the Claim Research dialog box, double-click on a claim on the Unapplied Receipts tab or click the Assign Unapplied button. The search fields at the top of the Claim Research dialog box show all the known information about the unassigned receipt. If the payer index for the unassigned receipt cannot be identified, Unknown is selected under Payer Index for This Payment.
- To find a claim in Insight that matches the unassigned receipt, use the information pre-populated in the search fields, or you enter your own search criteria. Insight looks for matching claims as follows:
Claim #: Displays claims that match any part of the claim number
Amount: Displays claims that match any part of the claim amount. For example, 10 matches 100, 110, 50.10, and so on.
Payer: Displays claims that match any part of the payer name.
Patient Last, First: Displays claims that match any part of the patient first and last name.
Service Date Start, End: Displays any claims that have service dates between the start and end dates.
Clearing any field causes that field to be excluded from the search.
Tip: Since all search criteria fields are pre-populated with information from the unassigned receipt, you should clear at least one field (typically the Claim #) before you begin your search. This causes Insight to locate claims other than the one indicated by the unassigned receipt.
- Once you have entered search criteria, click the Search button. All clims matching the search criteria are listed.
- Look at the name of the payer in the Payer text box. Then look at the payer index selected under Payer Index for The Payment (for example, Secondary). Verify that the Payer text box identifies the same payer as the payer listed in the corresponding column (for example, Secondary) in the grid. If the Payer text box identifies a payer listed in a different payer column (for example, Primary) than what is specified under Payer Index for the Payment, click the correct setting under Payer Index for The Payment . For example, if the Payer text box shows Regence BCBS and Secondary is selected under Payer Index for The Payment, make sure that Regence BCBS is listed in the Secondary column. If Regence BCBS is listed in the Primary column, change the Payer Index for The Payment selection to Secondary.
- Click on the claim to match to the unassigned receipt and then click the Use Selected Claim button. The dialog box closes. All unassigned information is updated on the selected claim.
If the remittance contains information about credit, the Credit Information tab identifies it..
Credit Information tab fields:
- Reason and MC Code: These fields indicate the Medicare code and reason for the credit. For a complete list of these codes, see the topic Denial and Adjustment Reasons in the Billing help.
- FCN #: Financial control number
- HIC #: Health insurance claim number
If there are no unapplied receipts and there are claims that have interest payments from the payer, the Interest Payments tab lists them. You can also display this tab at any time by clicking on it. You must apply the interest.
- Double-click on the interest payment to open the Enter EOB Items dialog.
- Manually reduce the adjustment amount for one of the lines on the claim by the interest payment amount.
- Manually increase the payment amount for that line by the interest payment amount.
- Click the Save & Close button to close the Enter EOB Items dialog. On the Payments tab, notice the check box in the Applied column for the claim. This indicates the interest was applied. You can select or clear this check box; its setting is save.
The original ERA amounts are saved separately, and all manual changes to amounts are tracked.
Handling Take Backs
If a payer submits payment and take back information in the same remittance advice, the amounts are accumulated and only the final results are shown. For example, if the first instance of a claim indicates that -$50 is the payment for CPT 97110 with a service date of 8/1/2008, and the second instance of the claim indicates that a payment of $40 is made for the same item, only an entry of -$10 is made for that item. If the net amount is zero, no entry is made. Note that the remittance information is preserved; only EOB entries show the combined result.
Entering Denial and Adjustment Reasons by Code
When entering denials or adjustments, you typically select a reason from the Denial Reason drop-down list. The list of reasons available are the standard Medicare denial reasons, which include denial codes. For a complete list of these codes and reasons, see the topic Denial and Adjustment Reasons in the Billing help.
To facilitate entering these denial reasons, you have the option of entering denial codes rather than selecting a reason from the drop-down list. To do this, check the Display Reason by Code check box.
This check box remains checked for other EOB entries. You can uncheck it at any time.
For each payment, be sure the Payment Date is the same as the date of the ERA file. To change a payment date, click the Edit Payment button on the Payments tab. You can manually edit the EOB entries for each claim in the Enter EOB dialog box, just as though you manually entered the EOB. Once you are satisfied the ERA has been allocated properly, you can post the payment as you normally would. There may be cases where the payer sends payment information in advance of a payment. Leave those payments unposted until the check arrives.
If a payment from an ERA file is posted, an additional check box, Print Remit, appears on the EOB Processing Results dialog box. This check box is checked if the claim is billable to secondary or tertiary payers. You may check or uncheck the boxes as desired. When you click the OK button on the EOB Processing Results dialog box, a preview of the remittance printout displays. You can direct the remittance to your printer.
If an EOB indicates that the payer is forwarding the claim to another payer, the Crossover check box is checked instead of the Print Remit check box. When you click the OK button on the EOB Processing Results dialog box, the remittance printout doesn’t include claims that have the Crossover check box checked.
If the organization that made the payment does not match the payer at the current payer index, the EOB Processing Results dialog box includes an additional column, ERA Note, specifying the unexpected payment source.
Handling Payments That Need to be Applied in a Different Database
If an ERA file includes EOB information and payments for claims in more than one database, special handling is required. This applies to two different clients in the Insight database, not to a client that has claims in both Insight and TO databases.
When the ERA file is processed, each claim is checked to see if it belongs in the current database:
- If none of the claims belong in the current database, the process is aborted and you are notified that the ERA file does not contain information for the current database.
- If some of the claims loaded belong in a different database, you receive a notification message. If this occurs, you must reduce the payment amount by the amount belonging in other databases and leave unapplied those claims that belong in other databases.
You must then process the ERA file in the other databases, ignoring any amounts applied in the current database.
To delete a payment, remove all the EOB entries for a payment and then click the Edit Payment button on the Payments tab. On the dialog box that displays, click the Delete button. Once you do this, all the recorded ERA information for that payment is removed as well.
If there are multiple payments within an ERA file, and any of the payments are posted, the file cannot be re-loaded. If any payments are deleted that were contained in that file, they must be entered manually.
You can print remittances for any ERA claims that have been processed.
- From the Activities menu, select ERA Remittances.
- In the Print Electronic Remittances dialog box, enter conditions to specify which ERA claims to print remittances for:
- Claim Number: Locates all remittances for the claim number.
- Payment Date: Locates all remittances paid between the from and to dates.
- Patients: Locates all remittances for patients with a last name between the from and to names. If a name is only entered in the from field, remittances are only printed for that patient.
- Payer Group: Locates remittances for all payers in the selected group.
- Payer: Locates remittances for selected payers. You can select more than one payer.
- For Report Style, select Detail to print one remittance per page. Select Summary to print multiple remittances per page, in landscape format. Samples of each style of report are shown in the following pages.
- Click one of the print option buttons: Preview, Print, Save to Text, or Save to PDF. If you click a button to save to text or PDF, you must enter a file name and the file is saved in the selected format.