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This article covers the eClaims Ability within MacPractice. This ability is where you can find all of your electronic claims that can be submitted to our integrated clearinghouses, and where you can review claim statuses. You can also send and rebuild claims from the eClaims Ability.
While electronic and paper claims share some similiarities, It is important to note that a paper claim will not necessarily reflect the information that appears on an electronic claim. Many payers have very different requirements for eClaims than they do for paper claims. Printing out a paper claim to verify information regarding an eClaim will not be helpful, because the information won't always match between the two media.
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Before you can send eClaims
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The eClaims ability in MacPractice allows you to send, track and manage electronic claims.
Before you Before you can send electronic claims, you will need to begin the enrollment process with one of our clearinghouses. Please contact the MacPractice Enrollment department at 877-220-8418 if you have not enrolled for eClaims. After your enrollment, you will receive an eClaims training, during which the eClaims trainer will install and set up your eClaims template.
Clearinghouses that integrate with MacPractice
The following clearinghouses integrate with MacPractice:
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Before training, MacPractice recommends that you familiarize yourself with the MacPractice Ledger, and make sure you know how to enter procedures, post payments and create paper claims. Please review the Ledger documentation if you need assistance with this process.
eClaims Ability
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Interface
The eClaims ability is divided up into 3 panes. The area along the top contains 7 different tabs listing different claim statuses.
Your claims will be listed under the tab corresponding to the appropriate status (A).
When you have a claim selected, the area near the bottom left will display the claim details, listing all information on the eClaim (B).
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Claims Table
The Claims Table displays all eClaims within the selected bin that meet the selected filters. Within this panel the user may select a single claim or a group of claims by clicking a claim, or clicking and dragging the cursor, or hold <Shift> and click to select a block of consecutive claims.
Hold <Command> to select multiple claims that are not consecutive.
When a group of claims is selected within the Ready Bin, the user is able to click the Send button. This will send only the claims that are selected. The user can also manually move claims from one bin to another, or click the Rebuild button to update information on all of the selected claims.
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When you have a claim selected in the Claims Table, the area near the bottom left will display the claim details, listing all information on the eClaim. This is the Claims Details Panel.
The area on the bottom right will display the status updates and history for the selected claim, with the most recent information listed first. We refer to this as the Claim Status Panel. You will utilize this area to review problems with invalid and rejected claims, and can also use this information to see exactly when claims were sent, received, and so on.
If no claim is selected, the Details Panel and the Status Panel will be blank.
At the very top of the view, you’ll see the Send and Rebuild buttons. These are only available when you’re on the Ready tab. With any other tab selected, the Send button will be greyed out.
If the Send button is pressed from the Ready Bin, with no eClaims selected, all claims that are viewable in the Ready Bin will be generated into a .CLM file, also known as a Claim File or a Batch File. A .CLM file contains all individual claims, gathered into a single batch. If the template is for a partner clearinghouse, the eClaims will also be transmitted to the clearinghouse when the Send button is pressed.
Claim Details Panel
When a single eClaim is selected in the eClaims Table, the lower, left panel will populate with a list of claim details and fields. If the user clicks the drop down triangle, it will display a list of fields and values. The values as they are shown within the node are all values that could potentially be written to the eClaim file.
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Not all values that are shown in the claim details will necessarily show on the actual claim. Many values are only written to the eClaim file under specific circumstances. However, if the specific conditions are met, the value that shows in the claim details is the value that will appear on the claim.
For example: If 'Secondary Medicare Type', in the Primary Node is set to "Other Liability Insurance is Primary", this will only populate information in the claim file if the claim is a secondary eClaim that is going to Medicare. If the claim is a secondary claim that is going to Medicare, then the code, "47" will populate the claim, which is the numerical code for "Other Liability Insurance is Primary". If the claim is primary, or if the claim is going to a payer that is not Medicare, this information will not populate the claim file at all.
Claim Status Panel
Once an eClaim has been created, every activity that occurs with that eClaim is updated in the eClaim Status Panel. This is the lower, right panel within the main eClaims window. Each status will reflect the date and time of the activity, which user performed the activity, and which activity was actually performed.
Trace Numbers (CHC Only)
In the case of automated clearinghouse response, a trace number will be provided, as well as an accepted or rejected message. Automated clearinghouse responses are only provided by MacPractice's partner clearinghouse, Change Healthcare.
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Trace numbers will not be provided on Inovalon or DentalXChange-submitted claims at this time (Last updated 7/18/24) Furthermore, as of the time of this note, we are awaiting confirmation that trace numbers will be available on the new Change Healthcare platform. We will update this article when this is confirmed. |
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A trace number is an identifier that is assigned to each, individual claim when it is processed at the clearinghouse. When a trace number is listed within the eClaim Status Panel, the user can click on the trace number to send in a trouble ticket to MacPractice. If a user has a question about a claim, once the trace number is clicked, a window will appear. A classification must be selected, to indicate whether the ticket is in regards to a question or a problem. An email address must also be provided.
eClaims Tabs / Bins
Let’s break down each of the Bins in eClaims. These are sorted into tabs in the eClaims ability, and they relate directly with the different Claim Statuses.
Invalid Tab
Regardless of what clearinghouse an office uses, MacPractice will validate all eClaims that are created within the software. All electronic claims are expected to have certain information, regardless of what the claim's intended destination or clearinghouse. If expected information is missing from an eClaim, MacPractice will move the claim to the Invalid Bin. Any claims that are moved to this bin automatically by MacPractice will be displayed in red text.
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Whenever an eClaim is rebuilt from within any other bin, and if the claim is missing required information, it will move to the Invalid Bin. If missing information is causing a claim to move to Invalid, and the user adds that information to where it is missing within MacPractice, the claim will move from Invalid to Ready when the claim is rebuilt.
Ready Tab
When an eClaim is successfully created, it will go to the Ready Bin. These claims have passed all of the MacPractice validations and are ready to be sent.
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The Send Button is only usable from the Ready Bin. When the active bin is any other than Ready, the Send Button will be grayed out.
Sent Tab
Once claims have been successfully transmitted to a clearinghouse, or the .CLM file has been generated, all claims that were selected to be sent will move to the Sent Bin. What happens to these claims depends on whether the clearinghouse these claims have been sent to supports receiving eClaim reports in MacPractice or not.
You can check what our integrated Clearinghouses support in the Clearinghouses section of this article here: https://macpractice.atlassian.net/wiki/spaces/MPHelpDesk/pages/74645542/eClaims+Ability#ClearinghousesAbility+-+Overview#Clearinghouses-that-integrate-with-MacPractice
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If the clearinghouse is an integrated Clearinghouse that supports receiving reports, claims will automatically move from the Sent Bin to either the Accepted or Rejected Bin, once reports have come back from the clearinghouse indicating the clearinghouse status of each claim. For these integrated clearinghouse claims, If claims remain in the Sent Bin for more than 24 hours, try to manually receive reports. If new reports do not move claims from the Sent Bin, try receiving reports the next day. The claims are likely still new, and they haven't fully processed yet at the clearinghouse. If 48 hours have passed without your claim status updating after you receive reports, please contact our EDI support team. |
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If the clearinghouse does not support receiving reports in MacPractice, the Sent Bin will be the final location of these claims until you manually adjust their claim status. You’ll need to consult that clearinghouse’s electronic portal to get information on these claims after being sent. |
Rejected Tab
When receiving reports from MacPractice's partner clearinghouse, any claims that have been rejected by the clearinghouse or by the payer will be moved to this bin automatically.
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Occasionally a claim may reject at the clearinghouse or payer, and then later may be reprocessed. It is possible at that time for this same claim to be accepted. A report will come back from the payer or the clearinghouse that indicates the claim has now been accepted. However, no claims will ever automatically move from Rejected to Accepted. If a claim is ever rejected, then later accepted, it will need to be manually moved by the user to the Accepted Bin.
Accepted Tab
Claims that have not been rejected by the clearinghouse or the payer will move automatically to the Accepted Bin, once the associated report is downloaded. This will only occur for claims sent through the MacPractice partner clearinghouse, Change Healthcare.
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If a claim has been in the Accepted Bin for more than ten business days, and no payment has been received for the claim, it is important that the office call the payer to follow up on the claim. MacPractice cannot research a claim that has been sent more than 30 days ago, so it is important that any problem claims be addressed as soon as possible.
Paid/Closed Tab
eClaims move to the Paid/Closed Bin only as a result of user action. Reports do not affect the movement of claims to this bin.
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Any method of registering payment in MacPractice will affect the movement of eClaims to the Paid/Closed Bin. If an ERA is posted, and it contains payment amounts (including 0.00 payment amounts) for every procedure on an eClaim, the claim will move to Paid/Closed. If all procedures on an eClaim are paid through the Bulk Insurance Payments Manager, the claim will be moved to Paid/Closed. Also, if all charges on an eClaim are paid by manually posting an insurance payment in the Ledger of a patient record, the claim will automatically be moved to Paid/Closed.
Archived Tab
aims have been moved to the Paid/Closed Bin, they begin to pile up. It is recommended that claims not be left to sit in this bin for too long. It is a good idea to move claims that are over a few months old to Archived.
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In order to unarchive an eClaim, the user simply needs to either manually move the claim from the Archived bin or rebuild the eClaim. The former method will move the claim to whatever bin the user wishes. The latter method will either move the claim to Ready or Invalid, depending on whether the eClaim passes MacPractice validations or not.
As you work with eClaims
As you work with your electronic claims, they will be moved from tab to tab in the eClaims ability as their status changes. Each tab will also display the number of claims within the tab next to the name. If you do not see a number, it simply means MacPractice is currently loading that information. If you are in Many mode (that is, you don't have a patient selected), you will see all patients' claims of a given status within the tab.
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If you have a patient selected, you will only see that patient's claims. The number next to the status name will also show you how many claims you are viewing out of the total number of claims in that status. In the example below, we are viewing 2 out of 42 invalid claims. If a bin contains only s claims for other patients than the one that is selected, the bin will appear empty to the viewer. The numbers in the title tab will indicate there are claims in the bin, even if they cannot be viewed.
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Changing eClaim Status
You may manually change the claim status in the eClaims ability by selecting the claim, and using the "Move To" pop-up menu (A). Changing the status in the eClaims ability will also change the status in the patient's ledger as well.
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If you created a claim with the wrong template in error, you will need to create a new claim using the correct template. If the original claim has not been sent, you can delete it; if it has been sent to the clearinghouse, you should close or archive the original claim. |
Selecting a Claim to Edit or Review Details
Select a claim in the upper pane to edit the claim or review the claim details. With a claim selected, the bottom left hand area will show you the current information listed on the claim, including the provider, patient, primary, and procedure information, among others. This area should not generally be used to edit the claim information, because it does not fix the source of the problem.
MacPractice recommends making the change in the patient's record, and simply fetching the updated claim information in the eClaim itself by clicking the Rebuild button. Utilizing this method will fix the source of the problem, so that it does not occur again. If you make the change in the claim data in the eClaims ability, it will only temporarily fix the issue on the selected claim. Rebuilding the claim at any point will remove any data you have manually entered into the claim details.
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