This article will review claim issues and rejections with the Inovalon claims clearinghouse.

Locating your Claims on Claims Management Pro

To find your Claims on the CMP Portal, you’ll look for the Claims Menu:

Open

From here, you can find your Institutional and Professional claims, and you can also review specific batches of claims in the Batches selection. A batch is created whenever you click the Send button, and will contain the claims that you selected when you sent them.

How long does it take for claims to appear on Inovalon after sending them?

If your claim batch does not appear on CMP, it can take up to a few hours for batches to appear depending on Inovalon’s load at the time. You can verify that the file upload from MacPractice was received by navigating to the System Menu > File Manager when logged into CMP.

Once you’re in the File Manager, you’ll open the following folders and see if there are any files in the Import folder:

Partners > Mac####### > Imports

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What do these claim statuses mean?

• ERROR: Validation Failed: The transaction has errors that must be corrected before it can be released and sent to the payer.

• MODIFIED: Modified: The transaction has been modified.

• VALIDATED: Validation Success: The transaction has been validated.

• RELEASED: Released: The transaction is ready to be processed by the clearinghouse. The claims are still editable and have not been batched for processing to the payers yet.

• PROCESSING: Processing: The transaction has been locked by the clearinghouse for processing. Indicates that Inovalon has started processing the batch and no further changes can be made. The compiler runs Monday-Friday @ 8:00am, 10am, 1pm, 4pm, and 7pm and on Saturdays @ 8am, 10am, and 7pm.

• QUEUED: Queued For Transmission: The transaction has been queued for transmission to the payer. See “Claim Transmissions to Payers and Batch Schedule”. Once claims are batched, they are then submitted to the payer.

• TRANSMIT: Sent To Payer: The transaction has been sent to the payer.

• REJ_PAYER: Rejected By Payer: The payer has rejected the transaction.

• PAID: Paid: The payer has paid the transaction. View remittance for additional information.

• DENIED: Denied: The payer has denied the transaction on a remittance advice.

Problem: Special Characters In Insurance Company Name

Any special characters such as parentheses and other symbols in the Insurance Company name in MacPractice (References > Insurance Companies > Company Info Tab > Insurance Name) will cause claims to be stopped.

To resolve this, simply remove any special characters from the Insurance Name in MacPractice.

Problem: Error on CMP - Billing Provider Address Lines 1 AND/OR 2 cannot be a PO BOX

This will require the office verify the Physical Address in the Office Reference.

• Open the References Ability and open the Offices folder in the sidebar on the left side. Most practices will only have one Office reference.

• If the Mailing address contains a PO BOX - leave this alone. This does not need to be changed.

Click the Physical Location tab. Verify the address information. If missing, you’ll need to enter a physical address and click the Use Physical Location check box and Save.

Once this is done, create a new claim and send -or- rebuild and re-send a previously built claim.

Rejection: Provider Not Enrolled

In general, there are three steps to take when experiencing Provider not Enrolled rejections:

• Confirm there is an enrollment request for the Payer ID listed on the claim in Claims Management Pro under Settings > Inovalon Enrollment > View Status.

• Confirm the Payer ID on the claim matches the Payer ID on the enrollment request.

• Confirm that the Payer ID is approved and for the TIN/NPI combination on the claim.

Checking the Enrollment Status

First, you’ll need to verify whether the provider enrollment was approved in the first place. You can check on your enrollments in CMP by navigating to the Settings Menu > Inovalon Enrollments > View Status. An approved enrollment looks like this:

Please review the Inovalon Payer Enrollment Guide for more information on initiating enrollments and managing enrollment tasks.

Checking Federal ID Number

If the provider is already enrolled, then you’ll want to verify the following settings in MacPractice for the provider record in MacPractice. You can pull up a Provider User in MacPractice by navigating to the References Ability and selecting the Users node in the sidebar.

When this node is expanded, you’ll see a list of your users in the sidebar. Select the appropriate provider, and click on the Provider Tab. In here, you’ll want to check two settings:

• For the “Provider Tax ID on Claims” drop down selector, you’ll want this to be set to “Use Federal ID Number”.

• For the “Federal” field, you’ll want to enter the Provider’s SSN if this is blank.

In addition to this, you’ll also want to double check the References Ability > Insurance Companies node, and expand this to select the insurance company payer in your sidebar. Once you’ve selected the payer in question, you’ll click on the Provider IDs Tab and ensure the “Legacy Type Override” is set to “Use User Reference”.

Rejection: Submitter not Approved

These rejections are not always related to enrollment, but we recommend the following steps:

• First, confirm that the Provider is indeed enrolled (see Rejection: Provider not Enrolled for guidance).

• If the provider is indeed enrolled with the payer, you’ll need to contact the payer directly to determine why claims are being rejected. (For example; is it credentialing possibly?)

• If the payer has no guidance, then you’ll want to contact Support to get some assistance investigating your particular situation.