Electronic Claims Submission manual

Electronic Claims Submission Manual Requirements For The American Medical Association (AMA) and the Connecticut State Medical Society Providers

Electronic Claims Submission manual guides determine an “electronic claim” as a paperless patient claim form generated by computer software that is transmitted electronically over telephone or computer connection to a health insurer or other third-party payer (payer) for processing and payment. A “manual claim” is a paper claim form that refers to either the Centers for Medicare & Medicaid Services CMS-1500 form (formerly HCFA-1500) or a Uniform Billing UB-04 form, both of which are typically sent to the payer through the mail and require postage. Electronic claims submission helps physician practices reduce the administrative burden and expense generally associated with manual claims processing and submission.

The use of electronic claims can result in significant financial savings for both physician practices and payers. Health information technology solutions are on the rise as more physician practices are submitting electronic claims to payers. By doing so, physician practices may potentially realize increased practice efficiencies and savings in their practice’s claims revenue cycle.

The American Medical Association (AMA) and the Connecticut State Medical Society encourage the use of electronic claims by physician practices. Physician practices are also encouraged to enhance their electronic data interchange (EDI) capabilities and to contract with vendors and payers that accept Accredited Standards Committee X12 (ASC X12) standards, especially those mandated under Health Insurance Portability and Accountability Act (HIPAA) administrative simplification. These vendors should also provide electronic remittance advice (ERA), eligibility and benefit information, claim status and prior authorization, as well as electronic claims processing.

Physician practices can realize several benefits from introducing electronic claims submission into the practice’s claims revenue cycle. Electronic claims submission can:

  • Reduce the amount of time and resources physician practices devote to manual administrative functions—time that can be better spent with patients or focused on other practice efficiencies
  • Pre-audit claim fields automatically for potential errors before submission to a payer
  • Identify claim issues and provide online claim resolution before processing by a payer
  • Submit claims almost instantaneously to a payer
  • Reduce postage, supplies and mailing expenditures
  • Track a claim’s progress between intermediaries (e.g., a billing service or clearinghouse) and a payer through an electronic audit trail
  • Confirm a payer’s receipt of a claim through electronic reports
  • Expedite a payer’s claims processing turnaround and potential payment time frame
  • Improve the practice’s accounts receivable.

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