Frequently Asked Medical Clearinghouse Questions
What should we look for in a Medical clearinghouse?
Your first step should be to identify your top 15-20 medical insurance carriers you submit medical claims to and make sure these insurance carriers are on the medical clearinghouse list. Not all insurance carriers are setup to accept electronic medical claims so place a call with those insurance carriers and identify their method of accepting medical claims.
Next step would be to identify the number of patients a day you treat, the number of medical claims generated from those patients and identify the number of medical claims you will be submitting. Here is an example:
Doctor A treats on average 23 patients a day and creates 23 medical claims.
Averages:
- 10 patients Blue Cross
- 5 patients United Health Care
- 3 patients Great West
- 2 patienst Cigna
- 3 patients Self Pay
With these #'s we can assume that on average 20-25 claims will be going electronically to Blue Cross, UHC, Great West and Cigna. Some clearinghouses will charge you a per claim service. In this case it would be 20 claims x 20 days (average # of days the doctor works a month) = 400 claims you will be submitting to the medical clearinghouse. When you begin reviewing pricing you will have an idea of the top insurance carriers you submit to along with the average # of claims you plan on submitting to the medical clearinghouse each month.
Additional services like online eligibility, claim status, Remittance Advice, and Reports are offered by medical clearinghouse . Talk with your providersto see if these are services your medical office is interested in using. If the answer is yes, you will want to find a medical clearinghouse that offers these additional services or work with your practice management software to see if they offer these services.
Medical Clearinghouse List options?
Normally when reviewing the clearinghouses website they will show you a list of their insurance carrier payers they are connected with. Compare this list with your insurance carriers you submit claims to.
Medical Clearinghouse Upload File types/extensions?
- Print Image File (PIF)
- National Standard format (NSF)
- Ansi 837
Glossary of medical clearinghouse terms?
ERA or Electronic Remittance Advice: Notification of what they payor will pay on the claim which is the same information you would receive from your EOB or Explanation of Benefits.
NSF or National Standard Format: The NSF is a guideline for building electronic claims which consists of fixed-length (320 bytes) records.
PIF or Print Image Format: It is a completed CMS 1500 form without the form or background of the medical claim template.
ANSII 837 Format: HIPAA compliant version of the medical claim which has many format options.
Par or Participating Claims: Normally it means the provider or medical facility is credentialed with a particular health plan. When claims are submitted electronically through a clearinghouse for participating insurance carriers that clearinghouse gets reimbursed a fee per claim from the payer.
Non Par or Non Participating Claims: Normally it means the medical provider or medical facility is NOT credentialed with the insurance carrier and the medical clearinghouse does not get reimbursed for submitting claims electronically to them.
Claims Acknowledgment Report: A report that reflects all medical claims submitted. This report has an identifier to indicate those that passed the medical clearinghouses edits and were forwarded on to the insurance carrier and those that were denied will be found in your exclusion report with exclusion reasons.
Claims Exclusion Report: Medical claims that have been excluded along with the denial reasons. These will need to be fixed and rebilled electronically or dropped to a paper claim depending on the issue.
Practice Management System: A medical database to store patient demographics, schedule appointments, post charges and payments while identifying the status of any outstanding balances. For practice management software products that offer document and image storage you can retain chart information in your database like medical records, licenses, patient photos, insurance cards, and patient registration forms.
DME or Durable Medical Equipment: Check with your medical clearinghouse to confirm they submit claims electronically for Durable Medical Equipment.
Eligibility Verification: Confirm if a patient is eligible for medical insurance benefits while identifying what copayments, deductibles and co-insurance amounts are due.
Medical Electronic Statement Processiing: stop printing and stuffing patient statements in your office and outsoure this to clearinghouses to perform.
What types of services do Medical Clearinghouses provide?
- Online Patient Eligibility and Address verification
- Electronic Medical Claim Submission
- Medical Paper claims submitted by the medical clearinghouse
- Electronic Remittance Advice
- Real Time medical claim status
- Patient medical statements and Collection Letters
- Patient Portal to pay medical bills
Is it possible to find a perfect Medical Billing Software and medical clearinghouse solution?
Yes. But remember what may be perfect for one medical practice may be horrible for another practice. Medical software, Medical Clearinghouse and Medical EHR/EMR software vendors are constantly improving their medical software with weekly, monthly, quarterly enhancement releases to wow YOU the doctor and retain your business because they know you have choices. Yes, It is possible to find a great medical billing software, medical clearinghouse and medical EHR/EMR solutions today.
Why use medical billing software pro's website?
After many years of consulting doctors it seemed like we kept getting the question, "is there anything better?" Well, we hope to answer that question through this website.
This website was specifically created for doctors and office staff to gain the knowledge needed prior to making the phone call to the medical software vendor(s). You will no longer be on a demonstration wondering if this is the best it gets. You have choices!
Our hope is that this website gives you the power you need to make the right decision for your medical practice needs. You have some wonderful software vendors to choose from and we wish you the very best in your decision to find that perfect software.
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