Claimrev clearinghouse

OpenEMR Development
#21

Is the provider allowed to have a copy of the 835 directly from payer or it will be handed first to the clearing house bounced around possibly between other clearinghouses before finally it gets to the provider?

from CAQH webinar I watched it seems that it is passed first to the clearinghouse, and it could be bounced around between multiple clearing houses before provider get to know what happened to the claims. I attached a screen shot from the webinar

Screen Shot 2023-02-10 at 11.20.37 PM
Screen Shot 2023-02-10 at 11.20.37 PM1920×1200 163 KB

if openemr is able to receive 835 is there any video on how to?

#22

hi @Mohammad , currently openemr can only receive 835s through Fees->Posting->ERA Upload. The script there would have to be reworked to automate the process.

#23

You are correct that ERA’s may bounce around; that just really depends on the payer and which clearinghouses they will allow to send to them. Some payers only accept claims from one clearinghouse.

Now on to your question if you’re allowed to get the era’s directly, and again that depends on the payer but the answer is probably yes. But you would have to go to every portal of all your payers and download all the era’s that way.

I’ve found most government payers allow for direct connection, so as for me, I get a direct connection to the medicares around the country; so those claims and era’s are always direct. I find the Blues are the same way. I’ve always been able to get a direct connection for those as well.

The commercial payers tend to enter contracts with a “preferred clearinghouse” and that company makes money on both sides. The payer pays them and in turn they charge the provider. In cases like this I find the cheapest route to get the claims to the payer.

#24

Availity is dominating the industry especially with medicaid, and seems to be the gateway for possibly “single payer”, “national/international” transaction protocol, I see the marching towards that with slowly implementing SNOMED to replace, down the road, ICD10 because SNOMED is international, similar to what they said in the webinar comparing it to ATM machine, if you have a checking account in a small credit union in BFE in the boonies and you go to Paris you can use the ATM machine in Paris to withdraw money from the machine as long as your funds suffice, so the transaction protocol in place is global, same here, they are moving the transaction protocol of 835 to be across the pond from US to global, that is why we are inching towards single payer wether we accept it or not.
So as far as Availity, I think we need to have openemr integrate with it if the project is going to be future proof.

#25

Availity is my competitor, so my module isn’t designed to work with them. There customer service is difficult and takes a long time to work with. At least in my experience.

Medicaid’s usually have a direct connection option, but every state could be different.

What you get with me is easy to reach person and a personal connection. Also, if i have to send to Availity, i handle those phone calls to Availity if files wont process…

As far as integrations, i can add to the module different api connections. Ill setup those connections from whatever gateways are required. I take the cheapest options i can to keep costs down. Which i try to pass along. I also don’t normally charge programming time to make that happen.

Im sure you can find a vendor that will write you a module to connect to availity api’s. But last time i checked with them i was told it was a minimum of $1000 a month for the privilege to have access to actually write the code.

#26

Why Molina ( Almost all Michigan medicaid…I can say 2 out of 3 patients you see in practice) is shutting off their portal and switching it to Availity? this is a government medicaid endorsing Availity all the way, what does that mean?

#27

Just looking up Michigan medicaid. They allow any clearinghouse to connect and send directly to them. I would send straight to them and if they return era’s get them straight from the source.