eClaims - ProxyMed Template

Owned by Dylan Nigh
Last updated: Sept 22, 2023
6 min read

The ProxyMed template is the medical claims template used to upload claims to Change Healthcare (formerly Capario). eClaims sent to Change Healthcare can receive status updates in MacPractice in the form of eClaim reports. These reports will be automatically attached to claims whenever possible, and will subsequently move the claim to the correct status tab automatically. After sending claims, MacPractice will prompt the user to receive reports.

MacPractice recommends receiving reports at least once a day. If claims are sent once per day, ideally the reports for claims sent the day before should be available to receive. Clicking Receive will check for any status updates from the clearinghouse on any claims. Please do not force quit this process. If the MacPractice computer experiences any issues while receiving, such as power outages or hardware failures, it is possible that claim statuses will not be updated properly. If this does occur, please contact the EDI division of the MacPractice Support department for assistance.

If the prompt to receive reports is dismissed, it is possible to manually receive at any time by selecting the Reports node in the sidebar of the eClaims ability. Click the Receive button to check for reports. Make sure the “Template To Receive From” pop up menu is set to the correct template.

Once reports are received, they will be listed below the Reports node. Different types of reports will be listed, such as INS, REC and ANC reports. Additional reports may be available for those who are enrolled in ERA services.

  • REC: A report from Change Healthcare that provides status updates on claims received by the clearinghouse. These claims have either been accepted and forwarded to the insurance companies, or rejected and stopped at Change Healthcare. Any claim rejected by Change Healthcare will not be forwarded on to the payer. Rejected claims will need to be corrected and resubmitted. REC reports will be automatically associated to their respective claims and will update claim statuses appropriately.

  • INS: An insurance company report that provides status updates on claims received by the insurance companies. These reports are sent from the insurance company to the clearinghouse and forwarded on to the office. These claims have been accepted at the clearinghouse, forwarded on to the payer, and then accepted by the payer for processing or rejected. Rejected claims are often deleted from the insurance company's systems, so insurance company reps would not be able to look up information on the claims. All rejected claims will need to be corrected and resubmitted. INS reports will be automatically associated to their respective claims and will update claim statuses appropriately.

  • ANC: An insurance company report sent at the batch level. A batch level response will not give patient-specific information and will not automatically tie to claims in MacPractice. ANC reports may contain both accepted and rejected messages for any claims in a given batch. ANC reports will need to be carefully reviewed for any possible messages and rejections as these will NOT be in the rejected bin. Payers who send ANC reports often do not send any other reports, so these reports will likely be the only notification from payers of batch level rejections.

  • PRA: An EDI report that accompanies all downloaded ERAs from Capario. PRAs include a summary of remittance information supplied by the payer, but cannot provide any auto-posting functionality.

  • TRN: An EDI report that accompanies all downloaded ERAs from Capario. TRNs provide transaction summary information.

Once reports have been reviewed, they may be archived by clicking the Archive button. Archived reports may be retrieved at any time by clicking the Unarchive button.

Most reports will automatically tie to claims in MacPractice. They will be displayed in the claim status area when a claim is selected. Claims rejected by either the clearinghouse or the payer will be moved to the Rejected tab, and claims accepted by either will be moved to the Accepted tab. If reports are received daily, claims should only stay in the Sent tab for 24-48 hours. If claims remain in the Sent status for any longer, please contact MacPractice EDI support, at 877-220-8418, to troubleshoot any possible issues with the claim.

Accepted claims

Claims in the Accepted tab have either been accepted by the clearinghouse or the payer. All accepted claims can be viewed by selecting the Accepted tab. Select a claim to view the status updates below and to view the status update messages. When an eClaim report automatically moves the claim from one status to another, the status update message will say "via Auto Report Apply." This simply indicates that the user downloaded a report that changed the claim status. To be taken directly to the report under the Reports node, the user can click the “Reported from Payer” or the “Reported from Clearinghouse” link.

Claims will stay in the Accepted status until they are either rejected in a future eClaims report, or until they are Paid/Closed. Claims will be Paid/Closed if the status is manually set to closed, or if a payment is posted to all procedures on a claim. No eClaim report will change the status to Paid/Closed.

It should be noted that a claim being in the Accepted tab does not necessarily mean the claim has been accepted for processing by the payer. Claims will have an accepted status once accepted by the clearinghouse, but not all payers will send status reports back. MacPractice has no control over the amount of information that is received from insurance companies, and any issues will have to be addressed with the payer.

Rejected claims

Claims in the Rejected status have either been rejected by the clearinghouse or the payer. Claims will stay in the Rejected status until they are fixed and resubmitted. The most recent rejection message will always be listed near the top, however all messages should be read carefully. Some claims will be rejected because of multiple problems and each problem is usually listed separately.

Once problem claims are reviewed, the problem should be corrected at its source. Information on the claim details should not be manually corrected, because any time the claim is rebuilt the changes will be reverted, and any new claims that are created will likely have the same problem. Fix the issue where ever it occurs in MacPractice and rebuild the claim.

To rebuild a claim, select the claim in the eClaims table and click the Rebuild button. When rebuilding, MacPractice will check for any updated information for the patient, and fetch that updated information on the claim. As long as the claim then passes MacPractice validation, it will be moved back to the Ready status for resubmission. If it does not pass MacPractice validation it will be moved back to the Invalid status.

'Some rejection messages may be rather cryptic, especially rejection messages from payers. MacPractice has compiled a list of some of the most common rejection messages. Many are articles in the https://macpractice.atlassian.net/wiki/pages/createpage.action?spaceKey=MPHelpDesk&title=eClaims%20Ability&linkCreation=true&fromPageId=74875004.

 

For assistance with rejected eClaims, please contact the EDI division of the MacPractice support department at 877-220-8418. Please provide the 15-digit trace number listed above the rejection message. Alternatively, the trace number can be clicked in order to submit a ticket to MacPractice that already contains the trace number. Please only submit one ticket for each rejection type.