Did your list of New Year’s Resolutions include any of the following?

1. We will not transmit pharmacy claims via modem.
2. We will no longer pay for dedicated phone lines.
3. We will set up insurance companies to submit claims via the Internet, file upload or FTP for direct payor submission.

It’s still January, so technically, it’s not too late to get going on those resolutions. Did you know that CPR+ offers transmission methods that will allow you to submit your claims electronically? Hopefully, your answer is a resounding “Yes!” Did you know the setup process is virtually painless? These methods will assist in reducing your A/R and increasing your revenue in a timely manner.

Electronic claims transmissions can be sent via several methods:

• through a clearinghouse
  - FTP for ZirMed or
  - ITS for Emdeon;
• directly to the Payor
  - FTP or
  - manual upload.

To begin submitting your claims via a clearinghouse, you’ll need to complete the enrollment process with the applicable payor and clearinghouse. After enrollment is completed, we will assist you with your CPR+ insurance company settings. (There are just a few settings that need to be changed.)

If you choose ZirMed as your electronic claims processor, you will be using SFTP (Secure File Transfer Protocol). In contrast, claims sent to Emdeon are transmitted via the Internet (ITS).

The other option is to send your claims directly to the Payor. Not all Payors accept claims directly, so you will need to contact the Payor - often times this information can be found on their website.

We are often asked how to setup payors electronically. While some payors require a bit more information than others, we can certainly get you started. This week, we will use Emdeon as an example.

Let’s start with Electronic Medical & Institutional Claims. First, you will need the Emdeon Payor ID. You can obtain this ID from the payor or the Emdeon Website. Once you have the Payor ID, you will enter it in the WebMD Medical # field. Directly below that, you will select Electronic Medical for the Requires Invoice Type as shown below. To access this window, go to Databases (7) > Insurance Companies (4) > Select a medical insurance payor and click the Edit (F4) button.

If the payor requires an Electronic Institutional format, you will need to select the Electronic Institutional Invoice type as in the following example.

Typically, there are only a few settings that need to be populated, which can be accessed by clicking on the Electronic Info (F8) button at the bottom of the window. Since the implementation of the NPI, unless specifically mandated by the Payor, most of the fields on this window can be left blank.

If billing for a drug item, the Payor may require the NDC to be submitted. If so, select Yes (Y) in the Submit NDC/RX Information? field.

The Default Type Of Claim field is located on the WebMD Medical Claims Setup window. Here you will select the applicable type from the pop-up list of Indicators. There are many options but only a few are commonly used. Listed below are the most common types:

• Commercial Payors = CI
• Blue Cross & Blue Sheild = BL
• Medicaid = MC
• Local Medicare = MB

In the next article we will discuss more about Direct Submission of Electronic claims to Professional and Institutional Clearinghouses or to the Payors themselves. I know what you are thinking, and Yes! - you can use a Clearinghouse other than Emdeon. Maybe you can even send to the Payor directly (provided they can accept FTP communications or have a place to upload the 837P or 837I files.) We’ll also discuss eligibility checks - for pharmacy and medical eligibility.

If you are interested in reducing your accounts receivables and increasing your revenue, watch the Weekly Infusion for more information on this topic.

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