Clearinghouses

Claims / Clearinghouses How do I enroll in a clearinghouse for claims processing?

CentralReach electronic claim services allow you to send claims electronically to most commercial insurance companies and government payers.  This process dramatically reduces the data entry error and speeds.  In order to use CentralReach’s electronic claims submission, administrators need to complete enrollment agreements with their payors for electronic submission where necessary.  Please contact each of your payors to determine if electronic claim submission registration is required.  Once those are complete, administrators should contact  their preferred Clearinghouse to subscribe to their submission services.

Step 1 – Enroll with Payor

Complete payer specific enrollment agreements.  These are sent directly to the insurance company or government agency (not CentralReach or clearinghouse).  Many payors will accept electronic claims submission directly from the provider using our 837P format, others may require submission through a Clearinghouse.

Step 2 – Enroll with Clearinghouse Vendor

Current supported clearing houses include: Office Ally, Zirmed.

Office Ally Enrollment Information

Register with clearing house for claims submission.  This service is free as long as 50% or less of claims are non-governmental.  Enrollment can be completed online by visiting http://www.officeally.com/register/enrollment.aspx.

        When signing up for OfficeAlly and stipulating the types of claims you will be submitting, please make sure to designate one claim type. The recommended claim type would be 837P                          Medical.

Once your initial Office Ally enrollment is complete and you have received your account you’ll need to call Office Ally’s customer service line at 360-975-7000 option 1 and ask them to activate your account for Secure File Transfer Protocol (SFTP).  This normally takes 24 to 48 hours and once complete you will receive an email from Office Ally with your SFTP username and another email with your SFTP password.  

ZirMed Enrollment Information

To enroll with ZirMed’s clearinghouse services you must first call their dedicated sales line at 877-995-9557.  They will review pricing and services and provide enrollment forms with instructions.  Once enrollment is complete they will provide you with both an SFTP username and password.

Availity Enrollment Information

To enroll with Availity clearinghouse services you must first contact Christopher Plante, cplante@centralreach.com.

Step 3 – Claims Manager Settings

Once you have received your SFTP information from the clearinghouse the next step is to update your claims manager settings.  To do so scroll over the claims icon and click settings.  Click the ‘Gateways’ tab from the left hand side to begin inputting your SFTP information.

Any questions or concerns on the Claims Submission process, please contact Customer Care using the Ticket System in your account.

Step 4 – Electronic Remittance Advise (835) Files

Once you have set-up your Gateway, you are able to begin the claims submission process.  In order to receive responses or payment information, the user must contact the payor to request that the 835 files be returned to the Clearinghouse.  Most clearinghouses will provide payor enrollment forms as a resource.

 

Claims / Clearinghouses How do I set up a gateway for my clearinghouse?

To set up a gateway within CentralReach you’ll need information from your clearinghouse.  To establish an SFTP (Secure File Transfer Protocol) connection between CentralReach and a clearinghouse you’ll need to contact the clearinghouse customer service department and ask them to activate your account for SFTP.  Once that is done they will send you an email with an SFTP login and password.  This will be necessary for the connection.  To set up the gateway scroll over the claims icon and click ‘Settings’.

CentralReach sends claims electronically to clearinghouses using a standard 837P file in a 5010 format that is HIPAA compliant.  Return files from the clearinghouses and payers themselves will include 277, 999, and 835 files. Typically you just need to request the 277 and 999 files be turned on. The 835 sometimes requires enrollment, please confirm if you need to enroll.

277 and 999 – This is an acknowledgment file from the clearinghouse stating the claim was received, accepted and sent on to the payer, etc.  When calling to activate your account for SFTP you will need to ask your clearinghouse what is necessary to be done to receive these type of files.  You may simply just need to request them to turn this function on as well.

835/ERA – This is a file from the payer, which will include payment, denial, etc. information, simply stated it is an electronic EOB.  You will need to contact each of your funding sources to see if they have any requirements before they will send 835 files back to your clearinghouse, which in turn is downloaded into CentralReach (the pre-register link 2 paragraphs above).

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From there click on ‘Gateways’ and then you will see an ‘Inactive’ tab.  Click your inactive tab and then click ‘Activate’ next to the clearinghouse that you would like to make active.  Once you have entered the gateway you will see three tabs.  The tabs and corresponding fields are below.

Edit gateway:

SFTP User – This is normally the username for your clearinghouse account.  For example, if you have an Office Ally login then you would place the username here – not the website username, this is the SFTP username, similar, but different.

SFTP Password – This is the password that you will receive from the clearinghouse once you have activated your account for SFTP.

Receiver ID Type (ISA07) – This field relates to the clearinghouse itself and is normally ’30 – U.S. Federal Tax identification number, but you may need to confirm.  For Office Ally use this identifier.

Receiver ID (ISA08) – This is the id to correlate with the above type.  For ZirMed and Office Ally we will pre-populate these fields.

App Receiver Code (GS03) – This is the id to correlate with the above type.  For ZirMed and Office Ally we will pre-populate these fields.

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Sender:

Sender ID Type (ISA05) – This field is going to correlate with how your organization registered with the clearinghouse.  It is normally 30 – U.S. Federal Tax Identification Number’, however, you may need to confirm with your clearinghouse.

Sender ID (ISA06) – This is the id to correlate with the above type. (i.e. your Tax ID).

App Sender Code (GS02) – This is the id to correlate with the above type. (i.e. your Tax ID).

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 Submitter:

Organization Name (1000A NM103) – This would be your organization’s name.

ID (1000A NM 109) – Use the same id you used in the ‘Sender’ tab.

Contact Name (1000A PER02) – This would be the name of your staff that you’d like to be sent along with the claim as a contact person.

Phone – Contact name’s phone number.

Email – Contact name’s email address.

 

The final check will be to return to the first tab, Edit gateway, and click on ‘Test the connection’, if you do not get confirmation of the connection, there is some type of error. If you do get confirmation, ‘Save’ the settings and you are all set to submit via CentralReach.

 

Note: Don’t forget, if you haven’t already to have the 277 and 999 files turned on, and begin the process to receive 835/ERA’s as needed.

 

Claims / Clearinghouses How do I set up my electronic claims and receive ERAs back?

If you are sending claims electronically within CentralReach but you are not receiving any responses, as explained in our Setting Up a Gateway help article, please make sure that your 277 and 999 communication channels are turned on within your clearinghouse account. Typically, you may simply have to request from Office Ally or your gateway that they “turn on the 277 and 999 files.”

Additionally, please make sure to check with your payors to see if they have any requirements with regards to 835/ERAs. We advise that you check with each of your funding sources to see if they have any requirements before they will send 835 files back to your clearinghouse, which in turn is downloaded into CentralReach.

Lastly, if all of the applicable requirements above have been met, please contact your clearinghouse to make sure that the ERAs that the payors send back to your SFTP folder are in 5010 format. Some payors use 4010, which is the outdated version of ERA files. As CentralReach is only compatible with the newer 5010 format, please have your clearinghouse alert your payors that you would like the ERAs to be sent in 5010 format.

Claims / Clearinghouses / Dashboard / My Profile How do I Setup My Account to Verify Client Insurance?

 

CentralReach provides the ability to verify client’s insurance information. In order to use this feature, the organization will need to download and execute an agreement with Office Ally. Once done, Office Ally will provide the necessary information needed to set up insurance verification, you must request CentralReach to turn on the insurance verification functionality within your account so you can update your settings.

For employees to have access to do insurance verification, they must have two permission rights: Insurance>Manage Verification Details and Insurance>Request Verification. These access rights can only be granted to employees by the organization Admin account.

Once the insurance verification feature is active for the organization and the employees have the proper permissions, the employee will need to configure their account to do insurance verification. To configure the employee account:

  1. Navigate to the Dashboard Module  and select Home/My Dashboard
  2. Click the My Profile tab
  3. Click the Settings tab
  4. Click  Insurance Verification

5. Upon clicking, you will be brought to Insurance Verification Settings. Complete the information based on the account details provided by Office Ally.

6. Click Save Settings.

Claims / Clearinghouses Office Ally – The In’s and Out’s

CentralReach uses two main clearinghouses – Office Ally and Zirmed. Both allow you to bill and post payments all within CentralReach. Zirmed charges a monthly fee. Office Ally, on the other hand, is free (minus one exception – see below).

Benefits of Setting up a Clearinghouse

There are two main benefits you gain when connecting your CentralReach account to a clearinghouse. The first, you can send out your claims electronically within CentralReach. No need to do this on third-party websites or portals. The second, you can receive payments, in the form of an ERA (electronic remittance advice), directly in your CentralReach account. You can then view, observe, notate, reconcile and ultimately post payments instantly with the click of a button.

Connecting CentralReach to Office Ally

In order to link Office Ally to your CentralReach account, you will need to obtain a SFTP Username and Password. This needs to be specifically requested. Upon account creation, Office Ally will give you a username and password – however, this is used to access their website. Usually, the SFTP Username is identical to the original but the SFTP Password will consist of numbers and letters totaling 8-12 characters. CentralReach will also need your company Tax ID in order to complete the connection. This is usually set up during Practice Management Implementation. If you choose to set up a gateway after Implementation is complete, please reach out to your Customer Success Manager via a Support Ticket and be sure to provide the aforementioned information.

277/999 Files

When setting up your account with Office Ally, also be sure to have them turn on 277/999 files.

EDI 277 is used by healthcare payers to report on the status of claims previously submitted by providers. Information provided in a 277 transaction generally indicates where the claim is in process, either as Pending or Finalized. If finalized, the transaction indicates the disposition of the claim – rejected, denied, approved for payment, paid.

EDI 999 is a transaction set that is used to confirm that a file or claim was received. It also includes additional information about whether the received transaction had errors. Having these turned on allows for seamless communication between CentralReach and Office Ally.

Charges

Office Ally is a free service. However, if 50% or more of your claims are being sent to Government/Non-Par(ticipating) Payers, or the payers listed here, Office Ally will charge you a monthly flat rate of $19.95.

CentralReach will charge .20 per claim. A single claim can contain up to 50 service lines.

*Please note that although Office Ally is a free service, they require a signed agreement (which can be cancelled at anytime).

Government Payers

There are six major government health care programs – Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program.

How to tell if it’s a Government/Non-Par Payer

If your payer isn’t listed above or perhaps it’s a sub-plan of one of the above, you can always check Office Ally’s website to verify if it is or is not a Government/Non-Par Payer. Visit the Resource Center and click on “Payer Lists.” From here, click “Professional & Institutional.” Next, search for your payer by name or Payer ID. The TYP column indicates the payer type – Commercial/Par vs. Government/Non-Par:

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The 5 cent OA tour

Claims / Clearinghouses Signing up for Insurance Verification with Office Ally

To sign up for insurance verification with Office Ally please follow the steps below:

  1. Complete Office Ally REAL TIME Eligibility Request (270/271) User Agreement.
  2. https://cms.officeally.com/OfficeAlly/Forms/Forms/RealTime_Eligibility_Request_User_Agreement.pdf?ver=2016-11-11-133158-470
  3. Email it to Sheila.Odeen@officeally.com
  4. Within email include which connectivity method you will be using – AS2 over HTTP
  5. Office Ally will send credentials within 24 – 48 hours.  These credentials will be different than any other credentials you may have received previously to login to Office Ally or to send claims.
  6. Once received enter credentials into CentralReach by going here.
***Please note that CentralReach charges $0.10 per individual insurance verification on top of any Office Ally charges.  Office Ally will invoice each organization separately.