Blumenthal Software
Electronic Claims Submission
Insurance claims can be printed on paper and mailed, or they can be printed to a disk file and mailed, or they can be printed to a disk file and transmitted electronically to the insurance company. Generally, both the second and third methods are referred to as electronic claims submission (ECS), but I will use ECS here to mean only the third method, of electronically transmitting claims to the insurance company. Since ECS data transmission formats and requirements vary enormously from area to area, I have made arrangements with an ECS clearinghouse, ClaimsNetwork of R.I., a division of The VSN Group, to serve as intermediary between PBS and the insurance companies. A clearinghouse is an intermediary company that accepts the claims from providers' offices, and then reformats those claims to the specifications of the appropriate local insurance companies. Contact ClaimsNetwork of R.I at 800-260-9395 Ext 134 or email: sales@vsngroup.com. Note that there are many other clearinghouses that will work similarly, and you can contract with any of them; a good source for contacts would be your local medical society.
How ECS works: You create a Print Job similar to any other one you have done for insurance printing, and select the HCFA 12-90 form, just as you would ordinarily. (Note, however, that you also have the option of selecting the SecureHealth form, which is 6th on the list of output formats on the insurance Forms page. The SecureHealth form is a variant of the HCFA form that eliminates some of the customizations that are unnecessary and problematic when submitting via ECS.) Set the output switch to go to a textfile instead of to the printer. Then, print with PBS the way you would ordinarily. You then exit PBS, and log onto the internet at www.securehealthclaims.com to send the file to ClaimsNetwork of R.I. There each claim is reformatted according to its insurance company's requirements and then sent on to the insurance company. Within minutes of transmitting to ClaimsNetwork of R.I., they edit the transmission and you immediately know which of your claims were accepted and which rejected (e.g. because of a missing diagnosis or id number). You will need to establish an account with ClaimsNetwork of R.I. in order to start transmitting. They will walk you through the process and help you get started.
Hardware requirement: You will need a connection to the internet. This is usually done via a modem (a piece of electronic equipment that hooks up your computer to the telephone). Modems can be internal (inside the computer) or external, in a case of their own, often with an on/off switch and LEDs that indicate what the modem is doing.
Data requirements: All PBS or PBSW programs with release #910901 (September 1, 1991) or later have the ability to gather the data required for ECS.
ECS setup: You have to sign a contract with ClaimsNetwork / SecureHealth, who will then assist you to notify your insurance companies that you intend to submit claims electronically to them, and will help you with the initial testing. Further details about setup and the lists of codes are not included here because they change from time to time; they will be sent at the time the ECS module is purchased.
Current costs: If a claim (a claim is equivalent to an insurance form that can report a maximum of 13 charges) is edited and delivered to the insurance company, the charge is 25 cents per claim; if the claim is not delivered (because it is missing the diagnosis or the insurance number, etc., according to ClaimsNetwork / SecureHealth editing criteria) there is no charge.
If you have any comments, questions, or suggestions, please send email to info@blumenthalsoftware.com