Clearinghouses

Claims / Clearinghouses Issues Receiving ERA’s back from Clearinghouse or from the Payor

If you are sending claims electronically within CentralReach, but are not receiving any responses, it is due to the following reasons:

  • Your 277 and 999 communication channels are not turned on within your clearinghouse account. Typically, you will have to request Office Ally or Waystar (ZirMed) to turn on the 277 and 999 files
  • 835 ERA requirements missing: check with your payor 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 send 835 files back to your clearinghouse, which in turn is downloaded into CentralReach
  • Payor is not registered with clearinghouse: ensure the payor is registered with the clearinghouse. Payors can send checks, but without registration, they will not send the ERA
  • The clearinghouse is not permitted to receive ERAs from the payor: this can be payor specific, but usually, payors require you to call them after completing the registration process to turn on the 835 files
  • The ERA was sent to the clearinghouse in an incompatible format: the clearinghouse can convert these to 5010, but this is not turned on by default. Request the clearinghouse to turn on automatic conversion per payor and request them to convert any 4010s they currently have and put back in the outbox
  • The ERA never made it to the clearinghouse and they simply do not have it: a request must be made to the payor to send that ERA again

To help troubleshoot the issue, we recommend you to follow these steps:

  1. Contact the Payor: the ERA registration rules vary per payor and many payors require you to call them and confirm the registration after submitting the forms. ERA registrations also expire for certain payors, so it is very important to first confirm that the payor is sending this information and that they are registered with the clearinghouse.
    • What to ask the payor
      • Am I registered to receive ERAs?
      • Was the ERA sent to my clearinghouse?
      • Can you provide the full file name of the 835-file sent to clearinghouse?
        • Example: 123456789_ERA_STATUS_4010zip
        • This file is in an incompatible format, and therefore, you can then call your clearinghouse and ask them to convert these to 5010 by default
  2. Contact the clearinghouse
    • Confirm the 277 and 999 files are turned on
    • If the payor confirmed the file type is 4010, ask the clearinghouse to convert these to 5010, and any older 4010 requests that are in the queue
    • If you have a check number, ask the clearinghouse if they can locate the 835 (ERA) file in their system and ask for a complete file name
    • Confirm or request the ERA’s are sent back via your SFTP account in a 5010 format
  3. Open a support ticket with CentralReach
    • If the clearinghouse indicates they have the ERA in proper format and it still is not in the ERA list, create a support ticket with the following information:
      • Claim ID
      • Check #
      • File Name
      • Example: 123456789_ERA_STATUS_5010zip

Claims / Clearinghouses Setting up a Gateway for your Clearinghouse

To set up a gateway within CentralReach, you need information from your clearinghouse. To establish an SFTP (Secure File Transfer Protocol) connection between CentralReach and a clearinghouse, 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 username and password. This is necessary for the connection.

To set up the gateway:

  1. Navigate to the  Claims module and click Settings
  2. Select Gateways and then you will see an Inactive tab
  3. Click the inactive tab and then click Activate next to the clearinghouse you want to make active
  4. Once you have entered the gateway, you will see three tabs: Receiver, Sender, and Submitter

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 payors 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 payor, etc. When calling to activate your account for SFTP, ask your clearinghouse what needs to be done to receive these type of files, such as requesting them to turn this function on.

835/ERA – This is a file from the payor, which will include payment, denial, etc. information. Simply stated, it is an electronic EOB. Contact each of your funding sources to see if they have any requirements before they send 835 files back to your clearinghouse, which in turn is downloaded into CentralReach.

Edit gateway

  • SFTP User: normally the username for your clearinghouse account. For example, if you have an Office Ally login, place the username here, not the website username. This is the SFTP username, similar, but different
  • SFTP Password: the password you receive from the clearinghouse once you have activated your account for SFTP
  • Export: creates a claim file (E.g. 837 file)
  • Dropoff: sends claims to a gateway
  • Pickup: CentralReach picks up the claims, 835, and ERA files from the clearinghouse
  • Receiver ID Type (ISA07): the clearinghouse itself and is normally, 30 – U.S. Federal Tax identification number, but you need to confirm. For Waystar (Zirmed), select ZZ – Mutually Defined in the drop-down
  • Receiver ID (ISA08): the ID to correlate with the above type. For Waystar (Zirmed), this is the SFTP username
  • App Receiver Code (GS03): the ID to correlate with the above type. For Waystar (Zirmed), this is the SFTP username

Sender

  • Sender ID Type (ISA05): correlates with how your organization registered with the clearinghouse. It is normally, 30 – U.S. Federal Tax Identification Number, however, you need to confirm with your clearinghouse. For Waystar (Zirmed), select ZZ – Mutually Defined in the drop-down
  • Sender ID (ISA06): the ID to correlate with the above type (E.g. Your Tax ID)
  • App Sender Code (GS02): the ID to correlate with the above type (E.g. Your Tax ID)

 Submitter

  • Organization Name (1000A NM103): your organization’s name
  • ID (1000A NM 109): your organization’s Tax ID number
  • Contact Name (1000A PER02): this is the name of your staff you want 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:

  1. Return to the first tab, Edit gateway
  2. Click on Test the connection, if you do not get confirmation of the connection, there is some type of error
  3. If you do get confirmation, Save the settings and you are all set to submit via CentralReach

Please note, if you do not already have the 277 and 999 files turned on, begin the process to receive 835/ERA’s, as needed.

Claims / Clearinghouses Claim Processing Clearinghouse Enrollment and Set Up

CentralReach supports electronic claim submissions, so claims can be sent electronically to most commercial insurance companies and government payors. To set up your organization for electronic claim submissions, the organization account has to complete enrollment agreements with their payors and must subscribe to one of CentralReach’s supported clearinghouses services, Office Ally or Waystar (ZirMed), as further detailed below.

  1. Enroll with payor: complete payor specific enrollment agreements. These are sent directly to the insurance company or government agency (not CentralReach or clearinghouse). If enrolling with Office Ally (details below) as the clearinghouse, they will provide you the forms and advise how to submit the request to your payors
  2. Enroll with one of CentralReach’s supported clearinghouse vendors:
    1. Office Ally:
      • There is a Non-Par monthly flat-rate of $35.00 for users that send over 50% of claims volume to Non-Par Payors
        • On February 1, 2019, the $35.00 Non-Par processing fee will be calculated and charged per unique Tax ID + Rendering NPI combination. If there is no Rendering NPI, Billing NPI will be used
        • For each unique Tax ID + Rendering NPI combination with a claim volume of 50% or more to Non-Par Payors in a month, the $35.00 will be charged for that unique Tax ID + Rendering NPI for that month
      • Enrollment can be completed online by visiting http://www.officeally.com/register/enrollment.aspx
      • When signing up for Office Ally and stipulating the types of claims you will be submitting, please make sure to designate one claim type. The recommended claim type is 837P Medical
      • Once your initial Office Ally enrollment is completed and you have received your account you will need to call Office Ally’s customer service line at 360-975-7000 (option 1) and request them to activate your account for Secure File Transfer Protocol (SFTP), and to turn on 277 and 999 files. You can also request this by email at info@officeally.com. This process normally takes 24 to 48 hours and once completed, you will receive an email from Office Ally with your SFTP username and another email with your SFTP password
    2. Waystar (ZirMed):
      • Call the dedicated sales line at 844-692-9782 to review pricing and services and get enrollment forms with instructions
      • Once enrollment is completed they will provide you an SFTP username and password
  3. Claim Manager Settingsonce you have received your SFTP information from the clearinghouse, the next step is to update your claims manager settings to set up your gateway. To complete this process, please contact your CentralReach Customer Support Specialist