Viewing Submitted Claims

File Transmission setting

The File Transmission drop-down field (in Master Files | Receivers) indicates how the software handles claims for payors associated with the receiver ID. Each receiver ID record can be setup with one of the following file transmission options:

● HCF Transmits: Enrolled in firstREV — Indicates that claims associated with these payors are edited using firstREV. HEALTHCAREfirst will submit completed claims for this payor from firstREV.

● HCF Transmits: Not enrolled in firstREV (Medicare only) — Indicates the payor associated with the receiver ID is Medicare and is not enrolled in firstREV (not required for Medicare payors). If this is selected and the “firstREV Claim Editor” box is checked, claims will be sent to firstREV (for editing).

o Users will edit these claims in firstREV (if applicable) and transmit them within the EE software.

o After editing and successfully validating claims in firstREV, users can retrieve clean claims in the Download Claims screen by clicking . A “Send” option will then display in the Action column at the far left of the display grid.

o When “Send” is clicked, the software will automatically submit the clean claims to Medicare via the ABILITY tunnel using the provider’s own Submitter ID.

o For claims that have been sent, a “Resend” option will display in the Action column at the far right of the grid. When “Resend” is clicked, the software will resend the claims to Medicare.

o After clean claims are sent to Medicare, a “Download” link will display in the Action column at the far left of the display grid. Users can click “Download” to manually download the 837 electronic claim file. This is optional, as agencies are not required to download the claim file.

● User Download Only — Enables the software to automatically return claim files to Download Claims so users can manually download the claim files and send them to another clearinghouse or directly to the appropriate payor.

o If the firstREV Claim Editor box is checked (Refer to section below), users will be able to send claims to firstREV (for editing) and then retrieve the claims by clicking in the Download Claims screen. Clean claims retrieved from firstREV will display in Download Claims and users can click the "Download" link to download the corresponding claim files. Users can then upload the files to the appropriate vendor.

o If the firstREV Claim Editor box is not checked, claims will not be sent to firstREV and will immediately display in Download Claims after they are submitted (in Post Batches tab). Users will not be able to edit claims with this setup.

firstREV Claim Editor setting

The firstREV Claim Editor checkbox (in Master Files | Receivers) indicates that claims associated with this payor are edited using the firstREV interface. The software automatically sends corresponding claims for this payor to firstREV (after they are submitted in Accounts | Billing | Post Batches):

● This is checked by default (and cannot be edited) if “HCF Transmits: Enrolled in firstREV” is selected in the File Transmission field.

● This is not checked by default (but is editable) if “User Download Only” or “HCF Transmits: Not enrolled in firstREV (Medicare only)” is selected in the File Transmission field.

For Medicare claims (with the appropriate file transmission settings), the software will submit the clean claims to your agency's designated Medicare Administrative Contractor (MAC) using the provider’s own Submitter ID when a user clicks Send in the Actions column. These claims can only be sent after the batch process has been successfully completed and the claim has been submitted (in the Post Batches screen).

Billing for other payors must be submitted by the agency (for non-billing clients) either by using firstREV, a separate clearinghouse, or by submitting directly to a provider portal.. Regardless of the payor type that is associated with a claim (i.e. Medicare, Medicaid, Commercial), users are able to download the corresponding files in Download Claims.

Status of Submitted Medicare Claims

After Medicare claims are submitted to your agency's MAC, the software will then update the status of the corresponding record in the Download Claims grid appropriately. 999 and 277 files are linked directly to the 837 file that is submitted to the MAC.

When checking the status of a submitted Medicare claim record, navigate to Accounts | Billing | Download Claims and, if necessary, use the search feature to find the desired claim record in the display grid. All available details for a claim file will be shown in the display grid.

Once the MAC processes the submitted claim file and returns it, the status of the file ("Accepted" or "Rejected") will display under the corresponding column for the claim file (i.e. 999 or 277 ). Users can then download the Medicare claim file.