How Claims are Processed

The Download Claims tab (accessed from within Accounts | Billing) has been simplified so that users are able to retrieve commercial claim files for sending to clearinghouses or directly to payers (if applicable). This screen has been changed to match the software interface, these revisions greatly simplify the process agencies use to interact with claims. These enhancements eliminate several steps and unnecessary clicks that were previously required. The following contains some general details about how the software processes submitted claims within the Download Claims screen.

Some of the general functionality that the software uses for processing claims in the Download Claims screen (for claims that have been submitted) is listed below:

● The specific method that the software uses for each claim file is dependent upon the File Transmission and/or firstREV Claim Editor settings established for the receiver ID record associated with the corresponding payor. These receiver ID settings are used to determine how the software handles claim files for each payor. Learn more about setting up receiver ID records.

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.

● All claims that are created in the Work With Batches screen and posted while in the Post Batches screen will be available for download in Download Claims (after editing and/or retrieving the claims from firstREV).

● When a user clicks

(in Post Batches), the software will automatically send Medicare billing to the designated Medicare Administrative Contractor (MAC) for your agency.

● Once available, the Medicare response and claims files will be available in this screen for users to download to their local drive (if desired).

● To make it easier for agencies to track sent billing, the 999 and 277 files are linked directly to the 837 file. The 999 and 277 columns in the display grid will remain blank until that specific file is returned from your MAC. Each file will be returned with a status of “Accepted” or “Rejected”.

● If your agency is enrolled for electronic remittance with your MAC, Electronic Remittance Advice (ERA) will also be included in the Download Claims screen. Users do not need to download these files and upload them into the Electronic Remittance Advice - Upload screen (in Accounts | Payments). The software automatically displays the ERA file in the Electronic Remittance Apply screen, awaiting approval for the payment to be posted.

How Submitted Claim Files are Processed