Claims:
| Possible Issues | Essential Info from PedsOne | Helpful Info from PedsOne | Other Considerations |
|---|---|---|---|
| Rejections | Patient PCC# and DOS | ||
| Status (did it go out?) | Patient PCC# and DOS | ||
| Denial | Patient PCC# and DOS | EOB from payer or ERA Ck # | Clearinghouses want a payer ref#, phone# and name of rep spoken to before they will pursue any denials |
| Dropping to Paper | patient pcc# and DOS | ||
| ECS config issues (NPI, taxonomy, etc) | patient pcc# and DOS; insurance plan name from ted #3 | ||
| HCFA config issues (NPI, taxonomy, etc) | patient pcc# and DOS; insurance plan name from ted #3 | scan of HCFA as printed noting updates needed - redact PHI before sending | printing a HCFA is not a reliable check of the electronic config - they are 2 separate set ups and often HCFAs aren't fully updated/synced to the electronic config |
| new Insurance plan config | scan of patient card - front & back |
ERA/835:
Possible Issues | Essential Info from PedsOne | Helpful Info from PedsOne | Other Considerations |
| Missing | Deposit date, Check #, Amount | Must be 3 full business days from date of deposit in order to open a case with the payer | |
| Missing - UHC Specific (UMR, Oxford, Golden Rule, All Savers, Student Resources, Medica, UHC Community) | Optum requires a copy of a downloaded ERA from their portal in order to open a case to have them research why it didn't deliver | ||
| Enrollment | Ins. plan name from TED #3 | PCC MUST INITIATE ALL ERA ENROLLMENTS IN ORDER TO PROPERLY LINK TO THEIR CHANNELS |
Eligibility:
| Possible Issues | Essential Info from PedsOne | Helpful Info from PedsOne | Other Considerations |
| New elig connection request | Ins. plan name from TED #3 | Patient PCC# and scan of card | Not all payers and/or clearinghouses support elig. PCC will check all their connections for supported elig. It is always worth asking PCC. |
| Not Working | exact error and code # from EHR and Patient PCC# |
EFT:
| Possible Issues | Essential Info from PedsOne | Helpful Info from PedsOne | Other Considerations |
| Setup | N/A | N/A | Caution should be taken by the practice or P! when setting up EFT to ensure EFT ONLY option is selected; there are often broken ERA connections when this isn't selected, which requires a brand new ERA Enrollment |
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