Before your eClaims training you may want to familiarize yourself with some eClaim terminology. You will want to be familiar with the terms listed below. Please review the Glossary for a full list of terminology.

Definitions

Change Healthcare (n., EDI) A medical claims clearinghouse supported by MacPractice. Change Healthcare may also be known by its former names, Capario, MedAvant or ProxyMed.

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trading partner (n., EDI) A secondary clearinghouse that acts as an intermediary between one clearinghouse and the payer.

Invalid v. Rejected v. Denied claims

The difference between invalid, rejected, and denied claims Claims sent electronically can be either rejected, denied or invalid. Invalid claims are stopped by MacPractice because of missing or incomplete claim information. MacPractice cannot filter for all billing criteria, but the software can catch some major issues before they get sent, enabling you to resolve issues quickly.

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Denied claims have passed every computer edit but were denied by the Payer's claims processing floor. Denials will come back to a provider via an EOB or ERA. Claims are typically denied for billing issues, which MacPractice cannot advise on. The payer should be the first line of contact for denials, as they are the source of the denial.

The difference between credentialing and enrolling

Being credentialed refers to having Provider information on file with a Payer for the purpose of sending claims. The office is responsible for all Payer credentials. MacPractice cannot offer any assistance or advice with the credentialing process, however Medicare requires an 855 form to be completed to gain acceptance into the Medicare program. Visit CMS for more information on the credentialing process. Many payers use the terms credentialed and enrolled interchangeably, therefore MacPractice uses the term enrollment to refer exclusive to EDI enrollment.

Several payers require an additional enrollment to send electronic claims. This might be known as an EDI enrollment, EDI agreement, Submitter agreement, and so forth. The MacPractice Enrollment Department will assist with the eClaims enrollment process if using one of our dedicated clearinghouses. To make sure the enrollment process goes smoothly, please make sure to provide all requested information and make sure that all credentials are up to date with all Payers.

The difference between Accepts Assignment and Participate

Accepts Assignment means that the provider accepts the carrier's allowed amounts. Definitions of Accepts Assignment vary by payer, the provider should contact the payer for clarification. Generally it means that the provider will receive the payment for the visit. For Medicare, Accepts Assignment means that the provider agrees to Medicare's allowed amount for the procedure and cannot charge the patient more than the contracted allowed amount. The provider needs to either use Medicare's fee schedule or needs to write off the difference between the office charge for the fee and Medicare's allowed amount.

Participate means that the provider is a participating provider with that carrier's network, or an in-network provider. Definitions of Participate vary by payer, the provider should contact the payer for clarification. For Medicare, participation means the provider agrees to always accept assignment of claims for all services furnished to Medicare beneficiaries. By agreeing to always accept assignment, the provider agrees to always accept Medicare-allowed amounts as payment in full and to not collect more than the Medicare deductible and coinsurance from the beneficiary.

The difference between Individual NPI and Group NPI

Individual NPI also often referred to as Type 1 NPI is a unique identifier that is associated with a person that provides healthcare services and submits medical or dental claims. The Individual NPI is used for the purpose of identifying a rendering provider.

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