Billing 101: The Lifecycle of a Claim in MediSked Connect

Billing 101: The Lifecycle of a Claim in MediSked Connect

Have you ever stopped and wondered – what actually happens when I click submit on a claim in MediSked Connect? If so, then this is the blog post for you. Welcome to Billing in Connect, an overview of MediSked’s Electronic Data Interchange (EDI) and Automated Billing. I’m Jason Nicholas and I drive our EDI team alongside our incredible Support Team at MediSked. I’m going to walk you through the entire billing process – following the submission of an agency’s claim from our MediSked Connect platform, through our HIPAA certified billing and automation to the payer, and finally following the claim acceptance back into Connect.

MediSked bills to hundreds of payers across the country. In 2017, MediSked generated and transmitted almost $2 Billion in claims to hundreds of payers across the country on behalf of our clients

837 Claim File

When a claim has been approved and submitted, its status is set to “Submitted, Not Sent” showing readiness to be transmitted to the payer, and the claim is entered into the payer interface active queue to be processed. Our automated billing software runs according to a set schedule to process this large volume of claims into files at agency specified intervals. We work with the agency and the payer schedule to process these claims as often as the agency chooses while allowing time to correct any issues or rejections before the payer cycle cutoff. Our most voluminous payers and agencies, such as Emdeon and eMedNY, run as often as every day with most of our agencies and interfaces being submitted weekly.

Our automation launches the scheduled job and our Ruby-based scripting programs navigate to the desired agencies and actively log every interface queue available with its currently reported interface claim count. After logging all claim, void, and replacement counts in each interface queue, the expected interfaces are processed by bundling all claims into files per each individual payer under that interface. At this point all claims have their status set to “Submitted, Sent.” These bundled claim files are saved to our EDI Servers for future referencing and auditing. Additionally, all logging and reports of the billing job are emailed as a transaction to our EDI team and the files are prepared for submission to the appropriate payer’s electronic portal.

Connect Automation Billing processed 5,108 claim files in Q1 of 2018

Submission & Processing

Our automated billing software connections are built to work with the most advanced and current technology to securely connect and comply with each payer’s specifications for electronic submission. After the claim has been processed into an 837-billing file and logging has completed automation uploads the files to the available electronic portal of each payer; through either a submission website or SSH File Transfer Protocol (SFTP) repository. Once the files have been submitted to the payer, additional logging occurs, and the transactional email is sent the EDI and Support team; alongside API posting of metadata on the 837s submitted back to Connect’s Billing Claim File Report. The transactional job emails are audited along with an audit of every file generated within Connect by myself and the Support team daily.

MediSked Connect has linked over 800 payers with ~180 separate Agency Interfaces currently using Automated Billing with connections to payers across the country

The claim at this point is marked as “Submitted, Sent” in the agency’s Connect and is being validated and processed by the payer or clearinghouse who will adjudicate the file and claims through several steps. When the payer receives the file they begin by checking the format of the files submitted, ensuring nothing is unexpected in the format and layout of the x12 type 837 data file. Once the file has been accepted, validated, and adjudicated the payer produces a 999 file, a direct response to the 837 file submission stating either that the file has been accepted for processing by the payer, errors were found with claims but the file will still be processed, or that the payer has rejected the file. Our billing automation retrieves these 999 files the same day of file submission, will post the payer acceptance status back to the agency’s Connect Billing Claim File Report and I personally confirm all 999 file acceptance, or will create a tracking ticket to address any rejected files to ensure all claims have been handled. If there is no response from a payer, this will be caught in a separate Payer Response Audit.

Provider agencies using Connect and Automated Billing generated $1.1 Million claims in Q1 2018

The payer continues to process the claim and within the same day produces a 277-claim status file which states the payer’s individual acceptance or rejection with each claim submitted. Automation retrieves these 277 files, uploads these back to the agency’s Connect site while also reading the claim status files. If a rejected claim is detected notification is sent directly to the agency to raise awareness of claim rejection and the uploaded file displays red signifying an action is required by the agency to further process an individual claim. The claim will process with the payer and within 1 to 2 weeks payment has been received by the agency and an 835-electronic remittance advice file is made available which provides details about providers’ claims payment, and if the claims are denied, it would then contain the required explanations. Billing Automation retrieves these files, uploads them to Connect, and reconciles associated claims. As this claim we have followed returns in the 835 file, the agency has been paid for the claim and the status of the claim in Connect will reflect the returned status stated in the 835 file of Paid or Denied. Once reconciled the claim has completed the billing process and the billing run has been completed! I hope this provides some insight into the inner workings of MediSked Connect billing. Our Support Team and I work and audit daily to ensure all claim, file, and acceptance billing processes are completed as close to 100% as possible to provide our agencies with the best EDI Support.

Jason Nicholas

Jason Nicholas

Jason Nicholas works at MediSked as an EDI Specialist and Billing Integration Engineer, working closely with Support to ensure 100% claim handling accuracy and constantly working to improve handling times and technology. He enjoys continuing to connect MediSked billing with new Providers, Payers, and Clearinghouses throughout the US while working to update and improve our existing billing scripting software.

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