Electronic Claims 101: The Future Is Now

There are many different options and providers for submitting claims electronically. The following are some of the basic features of self-service and full-service electronic claims:

“full service” electronic claims

Full-service electronic claims are submitted on behalf of a psychologist by a third party, often a billing service. The psychologist is only required to submit basic service and patient information to the billing service, which then develops and submits the claim directly to the appropriate insurer or a health care claims clearinghouse.

Reading: What is the system that insurance payers use to process claims submitted on

how much does it cost? The billing service often retains a percentage of the total amount of the claim as payment for its services. the percentage withheld often depends on the types of services provided and can range from 4 to 15 percent of the total amount of the claim.

“self-service” electronic claims

Self-service electronic claims are developed and submitted by a psychologist (or a psychologist’s staff member) directly to a third-party payer or health care claims clearinghouse.

Professionals who submit claims to only one or two payers may choose to submit their claims directly to the individual third-party payer using proprietary software provided by the payer.

See also: Is It Legal to Self-Pay If You Have Health Insurance? | eHealth

However, professionals who submit claims to many different third-party payers often find it more convenient to submit claims to a single clearinghouse, where claims are classified, formatted, checked for accuracy, and transmitted to the appropriate payer. Options for submitting claims to a clearinghouse include:

  • Direct File Submission. Some professionals use their practice management software to submit claims to a clearinghouse. The practice management software creates an electronic file containing the claims to be processed, and the file is sent to the clearinghouse through a secure telephone or internet connection.

  • direct data entry. professionals who are not comfortable using (or unable to use) their practice management software to file claims can still enjoy the benefits of filing claims electronically. Using direct data entry, the physician or his or her staff member logs into a clearinghouse through a secure Internet connection, enters provider, patient, and claims information into a formatted web page, often an electronic version of the hcfa 1500, and submit the claim for processing. The clearinghouse can retain patient, provider, and claim information in a secure system so that the physician does not need to re-enter all the information if they file similar claims in the future.

    Additional self-service claim submission options may be available for an additional cost, allowing professionals to perform functions such as:

    • verify insurance information such as patient eligibility, plan information, and copay amounts

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      Convert patient statements electronically for download into practice management software

    • check references, pre-certifications and authorizations online

    • Receive electronic remittances (eras) and electronic explanation of benefits (eob) statements from participating payers to immediately determine when a claim is paid and for what amount.

      The self-service option is often less expensive than using a full-service billing service for independent professionals and small practices, and it provides the psychologist with an additional level of control over the sensitive personal information contained in a claim.

      How much does it cost to file self-service electronic claims? pricing can be determined “per claim”, a flat rate, or a combination of a regular flat rate plus per claim fees. pricing may also be different depending on whether claims are entered via direct data entry or if a file is uploaded from practice management software.

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