This article covers the eClaims Ability within MacPractice.
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
The eClaims ability in MacPractice allows you to send, track and manage electronic claims.
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:
Change Healthcare
Accepts Medical Claims
Can submit claims directly from MacPractice
eClaim Reports are received within MacPractice (Meaning Claim Statuses will update automatically in MacPractice)
ERAs can be retrieved directly from Change Healthcare.
Requirements: Need a Static WAN Address
Inovalon
Accepts Medical Claims
Can submit claims directly from MacPractice
eClaim Reports are not available as of Build 15.18.6. This means that you’ll need to manually update claim statuses once claims are sent. You can track claim progress and status on Inovalon’s Claims Management portal.
ERAs can be retrieved directly from Inovalon with Build 15.18.6 when released.
DentalXChange
Accepts Dental Claims
Can submit claims directly from MacPractice.
eClaim Reports are not currently available to be retrieved. This means that you’ll need to manually update claim statuses once claims are sent. You can track claim progress and status on DXC’s portal.
This documentation has been written to provide you with additional information after your eClaims template has been installed and your eClaims training has been completed. This document is in no way meant to replace eClaims training.
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 Overview
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. We refer to this section as the Claims table. (A).
When you have a claim selected, the area near the bottom left will display the claim details, listing all information on the eClaim. This is the Claims Details Panel. (B).
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. (C). 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.
Claim Details Panel and the Claim Status Panel
When a single claim is selected, the specifics of the claim can be viewed in the Claim Details Panel. The history of the selected claim can be viewed in the Claim Status Panel. A single claim can also be rebuilt or manually moved. When more than a single claim is selected, no information will appear in the Claim Details Panel or in the Claim Status Panel.
If no claims are selected, no eClaim information can be viewed in the Claim Details Panel or in the eClaim Status Panel. With no claims selected, there is no option to rebuild or manually move claims.
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.
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.
The item that is causing the claim to be invalid will be indicated in red text within the eClaim Status Panel. The missing item will also be indicated in red text within the Claim Details Panel.
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.
Whenever an eClaim is rebuilt from any other bin, and when the claim passes MacPractice validation, the claim will move to the Ready Bin.
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#Clearinghouses-that-integrate-with-MacPractice
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.
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.
If the office does not use MacPractice's partner clearinghouse, Change Healthcare, claims will never move automatically. It is recommended that users manually move claims to the appropriate bin, based on whichever method claim statuses are communicated by the non-partner clearinghouse.
When a claim is sent through MacPractice's partner clearinghouse, and the claim has been rejected, either by the clearinghouse or the payer, the rejection message will appear in the eClaim Status Panel in red text.
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.
It is possible for a payer to reject a claim that has been accepted and sent along by the clearinghouse. If an eClaim is accepted by the clearinghouse, it will move to the Accepted Bin. If a subsequent report comes in for that same claim from the payer that indicates a rejection, the claim will then move to the Rejected Bin.
A status of "Accepted" from the clearinghouse does not automatically guarantee that the claim will be accepted at the payer. A status of "Accepted" from the payer does not mean that the payer is guaranteed to pay on the claim. The "Accepted" status only means that the claim met all technical criteria to be processed at the current entity and sent on in the next stage of processing.
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.
When all charges on an eClaim have had payment applied to them, including any 0.00 payments, the claim will move to the Paid/Closed Bin. If any procedures on a claim are left unpaid, the claim will not move to Paid/Closed.
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.
Claims that are in the Archived Bin will not be parsed when entering the eClaims Ability. They will only be parsed when the Archived Tab is selected within the eClaims Ability. Claims in all other bins will be parsed upon entering the eClaims Ability.
The parsing of claims doesn't take much time when there are only a few unarchived eClaims. However, the claims can gather quickly in other bins. The more claims that are parsed when entering the eClaims Ability, the longer it will take for the ability to load.
The only way that eClaims can be moved to the Archived Bin is by user interaction. The claims can be moved, either by using the "Move To" pop-up at the top of the eClaims Window, or by selecting the claim in the patient's ledger and using the "Other" pop-up menu.
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.
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.
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.
You should take caution when manually changing claim statuses however, as changing the status incorrectly may prevent the claim from being sent or processed.
If you have multiple templates in your database, you can also filter your eClaims list by the template, by selecting the template in the "Template Filter" pop-up menu (B). You cannot use this feature to change the template that the claim was created with.
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.
There are occasions in which the Rebuild button won't update new information. For further details on when not to use the Rebuild button, click here.
Claims will be assigned a status when they are initially created. The initial claim status will either be Invalid or Ready. Ready claims are claims that pass MacPractice validation and are ready to be set to the clearinghouse for transmission. Invalid claims have failed MacPractice validation and need to be reviewed before they can be sent. To review an invalid claim, select it in the eClaims ability. The pane in the bottom right hand corner will show you details about why the claim is invalid.
Missing information in the patient's demographics, the insurance company information or the provider's credentials could potentially cause an invalid claim, among other things. The types of invalid messages you receive will depend on your template. For example, the ProxyMed template for medical claims submitters will stop claims that do not have any diagnosis codes, but the EHG template for dental submitters will not.
Invalid claims will also be highlighted in red in the table above, and the area where the information is invalid will be highlighted in red in the claim data section. MacPractice recommends changing the source of the problem and the rebuilding the claim instead of manually fixing the information here.
Once you fix all issues with your invalid claim, select it and click the Rebuild button. As long as all issues with the claim have been addressed, it will be moved to the Ready tab. You will notice after a claim has been rebuilt, that the status area will change to show you which user rebuilt the claim and on what date.
Once you are ready to send your claims, make sure you have the Ready tab selected, and click the Send button.
Please note that if you select a claim, only that single claim will be sent. If you would like to send all claims, either select all claims or make sure you don't have any claims selected when you send. When you click Send, MacPractice will display an alert, telling you how many claims you are sending. Click OK. The software will generate your claim data and upload it to the clearinghouse. You may see MacPractice spin for a short while here, depending on the speed of your internet connection and the number of claims being submitted. Please do not force quit this process.
After uploading, you will receive a pop up menu letting you know whether your claims have sent successfully or not. If claims have been sent normally, the File Transfer Results window will say "Command Succeeded, Client exited with (0)" near the bottom of the window.
If you see anything other than "Command Succeeded," please check your internet connection and try again after a few minutes. If you continue to experience issues with claims submission, please contact MacPractice support.
Once your claims have sent, they will be automatically moved to the Sent tab. Generally speaking, you can upload your electronic claims as often as you like, however MacPractice recommends sending claims at least once a day to expedite the claims process. The availability of additional tracking at this point depends on what kind of template you are using.
