Claims Submissions: A Game of Assists

Follow these tips to help us help you

In basketball, a player that passes the ball to a teammate who successfully makes a basket is credited with an “assist” for helping score those points. The more the players help each other, the better chance the team has to score points.

Emdeon is in the business of offering assists to our channel partners. We’ve created products, services and a system of support, and we pass those on to you so you can score points with your providers. Of course, an assist works best when all team members are on the same game plan and giving it their all on the court. As Emdeon aims to support you in every way, it’s helpful to make sure all our efforts are collaborative—the essence of teamwork.

Here are some pointers regarding best practices for support issues. You can apply these tips to make sure Emdeon has everything needed to offer the best assists for your business.

•Deal with unpaid claims promptly.
When your providers face claims that remain unpaid, you often turn to Emdeon for an assist in the form of timely filing letters. Though we’re on the ready to help, our timely filing letters are only effective if sent as soon as possible upon detection of nonpayment.

Much like the shot clock in basketball counts down a player’s opportunity to shoot, payers impose limits on the timeframe in which claims can be reconciled. That’s why it’s essential that you work with your provider partners to keep an eagle eye on claim status. The sooner you alert us about unpaid claims, the sooner we can offer a timely filing letter to aid in adjudication.

•Have all details ready for timely filing letters
By the time it’s necessary to submit a timely filing letter, that aforementioned shot clock is really ticking. When you come to us to request a letter, have all the pertinent details on hand so we can act as fast as possible on behalf of you and your providers. Those pertinent details include patient name, insured ID, claim amount, date(s) of service, date of submission and payer name. Armed with this key information, we’re able to move ahead.

Please bear in mind that timely filing letters serve only as confirmation to payers that Emdeon received the claim and do not guarantee payment.

•Offer key information to help find ERAs that are MIA
When a remittance goes missing, turn to Emdeon to initiate a search within our system, and have the appropriate details handy—particularly in case we need to expand the search to payers’ systems.

At Emdeon, we just need to know payer name, check number, check date and payment amount to start looking. If we can’t find the missing remittance, payers can often start searching with only this basic information, as well. However, bear in mind that other details and protocols may be required. Here are examples.

- Medicare payers typically require a PTAN (Provider Transaction Access Number ) in order to offer support.
- Some payers require the NPI(National Provider Number) and/or payer-specific provider IDs.
- If payment was made via EFT, payers often ask for an EOB , Cigna requires a DDAR (Direct Deposit Activity Report).

Note that some payers will not generate an electronic remittance if they have not received and processed an electronic claim (e.g. - paper claims or claims generated via OCR/scanned claim information).

•Remember you have a stake in your provider’s claims process
While the claims submission process takes teamwork to complete successfully, it’s in the provider’s court to properly handle the initial legwork—accurate, prompt filing, diligent record keeping, etc. The smoother the provider’s claims submission process, the better payment outcomes and results will be for all involved.

Because you’re the provider’s direct link to claims submissions solutions and expert industry knowledge, it’s in your court to train and guide the providers’ processes. You can share our “How to Avoid Claims Rejection” quick-reference tool with your customers to help them navigate the challenges of claims filing.

When you play an active role in guiding providers to submit clean claims, you help ensure those claims pass the secondary evaluation by payers. We may reject claims based on our basic editing, as well as the use of some payer-specific editing. However, there are occasions in which claims pass our system yet are rejected at the payer level. If a claim does get rejected by a payer, please contact us with the Emdeon Claim Reference number or Emdeon File Reference number so we can assist in getting to the root of the problem.

•Keep track of the trace number to troubleshoot in real-time
To help you troubleshoot a real-time claim status, eligibility or referral transmission, we need the Transaction Reference Number, also known as the Trace Number. With that key bit of information, we can hit the ground running to help you help your customers.

If you don’t have this number, the next best information will be the eligibility logs 270/271 reporting, claim status logs 276/277 reporting, and referral logs 278 reporting. Make note: you can resubmit eligibility and claim status transactions to obtain the transaction or trace number, but providers should not retransmit referrals.

Remember to take advantage of the claim visibility and support tools available to you via Emdeon Vision and Emdeon ON24/7. Emdeon Vision for Claim Management provides your customer service staff with an end-to-end view into all claims from the point of submission to Emdeon through payer adjudication, while Emdeon ON24/7 provides flexible support tools that give you the service and support you need, when you need it, letting you submit requests online anytime or you can call into our office where our support staff will be happy to assist you quickly and effectively.

Follow these tips to help us help you, and together, we’ll achieve a truly winning strategy.

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Introducing Emdeon's Latest Innovations:

Two New Bigger, Faster, Better Solutions to Simplify Your Business...Again!

Have you ever seen a duck gliding on a lake? The image looks so serene, as sunlight gleams on the iridescent feathers of the duck skimming smoothly, seamlessly on the glasslike water. Yet just underneath the surface, the duck’s feet paddle quickly, furiously, relentlessly—in constant, concerted effort to keep moving forward. It takes lots of work to look that effortless.

Emdeon is much like that duck; our systems are ceaselessly working, and our people are endlessly innovating bigger, faster, better ways to simplify the business of healthcare. As our partner, you enjoy the smooth reliability of the more than 100 solutions Emdeon offers. You conduct business with seamless functionality because we’re constantly below the surface—paddling nonstop to save you time, money and effort in managing the revenue and payment cycle.

But at Emdeon, ‘bigger, faster, better’ is never enough, because our goal is to give you the services and support needed to be leaders. We stay in a mode of innovation to advance our existing solutions and pinpoint new ones to enhance your ever-growing, ever-changing business. Now, we’re pleased to report that all the proverbial paddling has paid off again in the form of two major innovations.

Introducing Emdeon’s data center additions and new, best-in-class print technology.

Emdeon Data Centers
On the occasion of the opening of the second of two new data centers, we invite you to look below the surface to get a glimpse of all that goes on to not only keep the single largest financial and administrative information exchange in the U.S. healthcare system going but to take its capabilities to new heights.

Our data centers deftly, reliably and securely transmit the unbelievable number of information exchange points and transactions the business of healthcare demands at any given minute, on any given day. Yet the volume of data exchanged is not nearly as impressive—or important—as what the new centers enable us to do with the data itself.

Rather than keep data chained together through separate business rules and processes as was required in the past, the technology behind our systems allows us to create data mash-ups, combining and aggregating data making information more useful and nimble.

Here’s a quick look at the advanced capabilities our data centers can enable.

For providers:
- Get paid sooner thanks to electronic claims that are auto-corrected and/or enriched with eligibility data to increase auto-adjudication rates.
- Receive remittance advice or estimate of payment within seconds of filing an electronic claim.
- Easily obtain comprehensive, accurate patient medical and prescription history within a collaborative care community.
- Monitor patients’ adherence to disease management protocols over defined periods of time within your collaborative care community.

For payers:
- Decrease call center and other operational costs thanks to minimization of errors or omissions on claims filed by providers.
- Detect insurance fraud prior to claims payment.
- Offer preventative patient care messages to providers based on patient medical and pharmacy histories.
- Eliminate pounds of paper currently received by mail or fax.

By bringing the new data centers online, we have streamlined many of our business processes, reducing the human factor and minimizing the potential for errors. By automating these processes, we can more accurately measure performance and anticipate issues before they become a problem. As a result, since the new centers have been online, calls into our call center have steadily dropped, while customer satisfaction has increased.

Our new, massive data centers live up to their billing as ‘state-of-the-art’ in every sense of the phrase. With hundreds of miles between them, these facilities are redundant yet independent to ensure all data is secure, safe and accessible without interruption. They exchange data at lightning-speed to eliminate downtime issues and further our capabilities as the single largest financial and administrative information exchange in the U.S. healthcare system.

•55,000 sq. ft. containing 2,000 servers
•2 petabytes of storage (That’s 2,000 terabytes!)
•20+ Load Balancers (10+ Redundant Clusters)
•900 Microsoft Windows Servers
•350 IBM AIX Unix Servers
•500+ VMWare Virtual Guests
•450 databases
•100% future growth potential

Unparalleled Printing Advancements
We have introduced the Pitney Bowes® IntelliJet™ 30 Printing System to herald the next generation in on-demand printing technology and patient communications production. As one of only three such systems in the world, Pitney Bowes IntelliJet™ takes the idea of “fast and high quality printing” to stratospheric levels. With amazing 1200x600 dpi output of 1,380 pages per minute, there is virtually no limit to what you can create, design and produce for your patient communications.
• Advanced print quality for razor sharp, vibrant patient statements
• Full-color statements in an extremely high resolution—1200 x 600 dpi
• Capable of four-color printing on both sides of the statement
• 1,380 pages per minute (400 feet of paper per minute)

With this new printing capability, Emdeon ExpressBill now has extreme capacity to handle patient statement production responsively in whatever quantities you need. We’re able to quickly update your statement design and content and print on demand—as needed, eliminating costs and waste associated with traditional, pre-printing methods.

Most impressively, this new printing system ensures statements enter the mail stream significantly sooner through logical presorting that combines postal codes prior to printing. This advanced capability eliminates the delays associated with the traditional USPS sorting process. Now we print your batches of statements in full color, in the presorted manner, allowing statements to hit the mail immediately upon print completion. Statements that get mailed sooner often lead to faster payment.

At Emdeon, we know we’re doing our job if you only see “the duck gliding on the water” with not so much as a worry about what must happen to keep things moving smoothly. Hopefully, this brief view beneath the surface deepens your appreciation for the innovations we’ve created. Now you can go about your business even more simply, while we keep ‘paddling’ to our next round of innovative solutions.

To learn more about Emdeon’s innovations and to view a video tour, please visit

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HIPAA Simplifed Update for Channel Partners

We are pleased to announce that Emdeon has received notification that we have met the requirements of the EHNAC 5010 Readiness Assessment Program. Emdeon received a score of 100%, which further evidences Emdeon’s commitment to ensure compliance with HIPAA 5010.

In addition to this industry recognition, Emdeon continues to guide our customers successfully through the migration to the X12 5010 and NCPDP D.0 versions of the HIPAA transaction standards. We have updated our gap analysis documents to include the recent 5010 Errata changes and we have enhanced our 5010 systems and products to support the Errata versions HIPAA transactions. The Errata versions of the gap analysis documents are available at the HIPAA Simplified website under downloads.

We strive to provide you with the most updated and accurate information regarding our readiness for HIPAA 5010. Please see below answers to the most commonly asked questions regarding HIPAA 5010.

What is Emdeon’s current state and plans for HIPAA 5010 testing?
Emdeon is currently testing and implementing 5010 with submitters and payers. The late release of the Errata changes to the 5010 transaction standards further constricted the already narrow 5010 testing and conversion window. Nevertheless, as you can see in the list below, Emdeon has initiated submitter and payer testing on all 5010 transactions.

Errata Beta testing in process:
• 837 Professional claims
• 837 Institutional claims
• 837 Dental claims
• 835 ERAs
• 270/271 Eligibility verification

Emdeon is also testing the Final Rule version with submitters and payers for the HIPAA X12 transactions that were not included in the Errata revisions:
• 276/277 Claim Status
• 278 Referral/Authorization

How can my organization initiate testing with Emdeon?
Emdeon has created HIPAA 5010 conversion tools to help automate the conversion for your convenience. To begin this process, please initiate testing through your ON24/7 account. Please refer to the Submitter Claim Quick Reference Guide to guide you further. Detailed instructions are also available on Emdeon ON24/7.

What Emdeon solutions are impacted by 5010?
5010 impacts eligibility, claim, claim status and remittance transactions. The associated Emdeon solutions impacted by 5010 include our clearinghouse and others including:
• Emdeon Office
• Emdeon Payment Manager

How will my organization be notified of any product updates if required?
Emdeon is actively working on finalizing a global plan communications we will be providing to our clients throughout the year. In addition, fact sheets will soon be available and distributed for each product line.

What is the timeline(s) of events?
Emdeon is committed to fully support 5010 standards prior to the HIPAA 5010 compliance date. The precise dates on which Emdeon will support 5010 standards will vary based on the product, transaction, payer readiness and client readiness. Our goal is to have all Emdeon products modified and testing completed by the end of the year in order to be ready for the January 1, 2012 compliance date.

Where can I obtain additional information about HIPAA 5010?
Emdeon created a valuable web resource available to all industry stakeholders titled HIPAA Simplified, which may be found at HIPAA Simplified is a one-stop online resource that features gap analysis, business level documentation, webinars, timelines for the transition and testing information for our customers.

Thanks for trusting Emdeon as your source for HIPAA readiness. We are working diligently to deliver solutions that enable our customers to seamlessly meet these industry regulatory requirements.

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How to Spot a Unicorn -or- The Accountable Care Organization Identified and Explained

What You Need to Know about ACOs

In a January 2011 news report, National Public Radio journalist Jenny Gold likened accountable care organizations (ACOs) to “the elusive unicorn: everyone seems to know what it looks like, but no one has actually seen one.”

The ACO has been a relatively hot topic since it was introduced as a provision in the new health law last year. The acronym fast achieved industry buzz phrase status as many in our industry began to eagerly hunt the proverbial unicorn without benefit of details or a roadmap. Most are aware ACOs fit in context with a better model for delivering care to Medicare beneficiaries; otherwise specifics are sketchy.

Here is the key information you need to know about ACOs—the corralling of the unicorn so you can have a better view.

Accountable care organization
əˈkountəbəl | ke(ə)r | ˌôrgəniˈzā sh ən

1 a type of payment and delivery reform model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients* *—as defined on Wikipedia
2 a recognized legal entity under State law and comprised of a group of ACO participants (providers of services and suppliers) that have established a mechanism for shared governance and work together to coordinate care for Medicare fee-for-service beneficiaries*
*—as defined by the Centers for Medicare & Medicaid Services

An ACO is an organized network of healthcare providers (hospitals, physicians, specialists) and is accountable to patients and payers, specifically Medicare. Provider participants collectively share responsibility for the healthcare of a group of patients for a set period of time. Specifically under the new law, an ACO must commit to care for at least 5,000 Medicare patients for a minimum of three years. The goal of an ACO is to improve the quality of care for patients while achieving cost savings, beyond the ACO’s historic national benchmark.

The intended benefit for patients is coordinated, well-rounded and more thoughtful care. Rather than receiving disjointed snapshots of care through referrals and provider visits, patients in the fold of an ACO would be part of a broader network. It’s kind of a “why buy the ingredients when you buy the cake already baked?” approach to healthcare.

The intended benefit for providers is the ability to give more efficient, results-oriented care while achieving cost savings that may then be shared amongst provider participants. Though still earning fees for service, ACO participants have the incentive of sharing in the savings, without full-blown capitation.

The intended benefit for everyone is aligned with the goals of ACOs in general: measurably better care and lower costs. Medicare is beleaguered, lumbering and struggling as an entity; those in positions of national leadership in health reform are banking on ACOs to achieve cost reductions and enhance care now while making the system viable for the longer term.

Under the provision of ACOs, providers will continue to receive fees-for-service, and patients will be free to select physicians outside the ACO network. The latter point is a key differentiator of ACOs from HMOs or health management organizations. This structural nuance is intended to avert possible control of patient referral patterns that some see as the bane of the HMO model (e.g. adverse selection). Additionally, antitrust reviews are to be expedited and coordinated by both the Federal Trade Commission and the U.S. Justice Department to ensure that no ACO is able to wield market power that drives prices up while keeping competition down, at least in theory.

The highly anticipated proposed rules were released on March 31, 2011 with a 60 day comment period. CMS received more than 1,200 comments, many of whom found ACOs bearing too many requirements with too few rewards. At the first ACO Learning Development Session on July 21, CMS Administrator Donald Berwick acknowledged the proposed rules caused debate and discourse and believes the final rule will take into account the thoughts and opinions of those who commented. Nonetheless, ACOs are part of the health reform structure and are poised to play a major role in our healthcare system moving forward.

Some of the comments from nationally recognized healthcare opinion leaders include:

• The American Academy of Family Physicians—“…The AAFP is concerned that the Medicare ACO program as currently proposed will fail to offer the potential benefits of better care for individuals, better health for populations, lower per capita costs for Medicare beneficiaries and improved coordination among physicians…"

• The Mayo Clinic—“…it (the rule) creates a sense of mistrust toward providers in a manner that suggests that CMS would not be a trustworthy and effective partner in the innovation that is necessary for us to really make progress in reform…"

• The Medicare Payment Advisory Commission (MedPAC)—“…Providers may be reluctant to commit time and money to reorganize the delivery system to better coordinate care and improve quality, if rewards are uncertain and difficult to calculate…"

Unicorn Sightings: ACO Dates and Milestones
Implementation deadline for ACOs is January 1, 2012.

In March 31st of this year, the federal government published proposed rules to guide the operation of ACOs. These rules establish comprehensive structural and quality requirements. HHS also released information for patients and providers to lay groundwork for ACO implementation. Upon release of proposed rules, many called for immediate review and modification.

On May 17th of this year, Centers for Medicare & Medicaid Services (CMS) unveiled three ACO initiatives to guide ACO structure and approach: the Pioneer ACO Model, Accelerated Development Learning Sessions and the Advanced Payment ACO Model.

Recent and upcoming ACO deadlines include:
June 6, 2011- NPRM comments closed
June 17, 2011- Cut-off for comments about advanced payment initiative to The Innovation Center
June 20 - 22, 2011- Training for Accelerated Development Learning
Session 1 in Minneapolis, also viewable by webcast
Session 2 September (TBA); San Francisco Bay, CA area
Session 3 October (TBD); Philadelphia, PA area (tentative)
Session 4 November (TBD); Atlanta, GA area (tentative)
June 30, 2011 - Due date for Letter of Intent for organizations interested in participating in the CMS’ Pioneer ACO model
August 19, 2011 - Application deadline for the Pioneer ACO Model
January 1, 2012 - Deadline for ACO implementation

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Discover new ways to simplify your business when you connect with Emdeon

Follow Emdeon on Facebook and Twitter to learn about innovative new solutions and special offers or to provide feedback on Emdeon products and services you use. Emdeon regularly posts updates and offers valuable resources to keep you on top of industry trends and current information, including healthcare reform, emerging technology, best practices and more. Use your computer or mobile device to receive Emdeon updates on free webinars, new product launches, important news articles and upcoming tradeshows. You can also visit our YouTube channel to watch inspiring customer testimonials and insightful product videos, or join Emdeon on LinkedIn to connect with colleagues. Click the icons below and get social with Emdeon today!


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New Payer Transactions Added Recently

New payers. Take a look at the new list
The Emdeon network of payers continues to grow. New transactions added recently:

•Combined Benefits Administrators; Claims; ID: 88059
•Dreyer Health; Claims; ID: DREYR
•MED PAY; Claims; ID: 88058
•Omnicare Medical Group (OMNI); Claims; ID: IP088
•Nebraska Medicaid; Claims; ID: SKNE0
•AIG; Claims; ID: 19402
•America First; Claims; ID: J1427
•Federated; Claims; ID: J1297
•Hartford; Claims; ID: J1422
•Liberty Mutual; Claims; ID: 33600
•Secura; Claims; ID: J1379
•Travelers; Claims; ID: 19046
•Golden Triangle Physician Alliance/SelectCare of Texas(GTPA); Claims; ID: TXNSE
•HEALTHe Exchange; Claims; ID: THEXI
•Central SeniorCare; Claims; ID: TXNSE
•Memorial Clinical Associates/SelectCare of Texas(MCA); Claims; ID: TXNSE
•Northwest Diagnostic Clinic/SelectCare of Texas(NWDC); Claims; ID: TXNSE
•Fresenius Medical Care; Eligibility Inquiry and Response; ID: FRSMC
•Generations Healthcare; Eligibility Inquiry and Response; ID: GENHC
•Katy Medical Group; Eligibility Inquiry and Response; ID: TXNSE
•Optima Health; Eligibility Inquiry and Response; ID: OPTMA
•Select Senior Clinic; Eligibility Inquiry and Response; ID: TXNSE
•Texan Plus (North Texas Area); Eligibility Inquiry and Response; ID: TXNNT
•Texan Plus (Southeast Texas Area); Eligibility Inquiry and Response; ID: TXNSE
•Today's Health; Eligibility Inquiry and Response; ID: TDHLT
•Today's Options; Eligibility Inquiry and Response; ID: TDOPT
•Tribute/SelectCare of Oklahoma; Eligibility Inquiry and Response; ID: TSCOK
•Village Family Practice; Eligibility Inquiry and Response; ID: TXNSE
•IlliniCare Health Plan; Eligibility Inquiry and Response; ID: CLINI
•Central SeniorCare; Eligibility Inquiry and Response; ID: TXNSE
•Fresenius Medical Care; Eligibility Inquiry and Response; ID: FRSMC

For a complete list of the payers in our network, visit our website at

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