Permissions: You must have Billing Permissions with the ability to "Submit Claims to Clearinghouse" enabled.
After a Claim is Accepted by the Payer you will receive an ERA with payment for that Claim.
If your Organization uses Claims with Apex Clearinghouse, you can enable a setting to have ERAs processed automatically.
NOTE: You will not typically receive the ERA Payment the same day the Claim is Accepted. It often takes time for the ERA Payment to process after the Claim is Accepted.
Enable Auto Processing
Once you receive the ERA, TheraNest will auto-process ERAs that match certain criteria. If an ERA is not auto-processed, you will be able to make adjustments, write off a balance, shift the balance to the client, or leave it as is from within the ERA Received tab.
- The ERA payment was received without any adjustments.
- The ERA payment was received were the only adjustments were Patient Responsibility or Contractual Obligation.
- If the adjustment was Patient Responsibility (PR-1, PR-2, or PR-3), an invoice adjustment will be created and the amount will be shifted to the client.
- If the adjustment was Contractual Obligation (CO-45 or CO-253), an invoice adjustment will be created and the adjustment amount will be written-off.
- Click the Organization tab and Claims Service.
- Click the Settings tab.
- Click Turned On for the Automatic claims processing setting. Claims will be automatically processed.
Process Payments One by One
- Click Actions for every Payment and select one of the following:
- Process Payment - This means you're taking the Insurance Payment and applying it to that Invoice/Claim on the Ledger. When you choose this option the Payment will automatically be applied to the Invoice/Claim. The ERA will then move to the Paid/Processed tab on the Claims screen.
- Mark as Process - No Payments are being applied to the Invoice but that Payment line moves to the Paid/Processed tab. If you accidentally marked a Payment as processed without applying, see below.
Manually Adjust an ERA
NOTE: This feature is only available for organizations who are using Claims with Apex Clearinghouse.
- Click Billing and then ERA Received Tab.
- Click Actions for the appropriate ERA you want to adjust.
- Click Process Payment Adjustments to match the action in the application.
- Claim Details display at the top.
- Adjustment Codes display.
- To add a Write Off - Enter the Write-Off amount in the field.
- To Shift Balance to Client - Enter the Balance amount in the field.
- To leave an Insurance Balance Due - Enter the amount in Do Not Apply field.
- After you have made the adjustment, the Remaining Amount, the Resulting Insurance Balance, and the Resulting Client Balance will be reflected below.
- Click Process Payment button to complete the adjusment.
Resolve a Mismatch
Occasionally when you receive an ERA, it doesn't match back up with the original Claim you submitted. If this happens, you will want to manually resolve the mismatch before you Process Payments
- Click Resolve Match.
- Select the appropriate Client.
- Select the appropriate Payer.
If you accidentally marked a Payment as processed without applying, you can reverse the movement.
- Go to the Paid/Processed tab.
- Click Actions next to the Payment.
- Select Mark As Not Processed. The Payment will go back to the ERA Received tab for you to apply.