Electronic Remittance Advice files are matched to the submitted claims within SOAPware. If the ERA returned by a payer doesn't completely match the claim information within SOAPware, the mismatched area will be shaded pink with a tool tip to help identify the error. Once these mismatched items are changed in SOAPware to agree with the information on the remit, future remits for that payer/patient will match and not return with errors.
- The Post Payment button is not enabled until all errors are corrected.
- Most errors can be corrected by Matching patients or claims that are shaded pink.
- If changes are made in patient demographics and Insurance Company setup, to match the way they are returned on the remit, this will reduce the amount of errors for future downloads.
Payers received in the 835 file are mapped to the Payer ID listed in the Electronic Submission Info in Tools>Insurance Companies. When a claim is selected and the Payer section of the Remit View is pink, it must be manually matched.
- Click the ellipses to open Select Insurance Company dialog. If several insurance companies in SOAPware have the same 5 digit Payer ID, those payers will be listed.
- Select the Edit icon if needed to verify the appropriate payer from the list and click Select.
- If the correct payer isn't found in the list, place a check mark in the Show All box and scroll to find another payer, highlight and Select.
- If payer still isn't found, select the + icon to add a new payer.
- Highlighting and Selecting a payer from the Insurance Company list will remove the error and enable the Post Payment button if this is the only error (pink area) on the remit.
- Editing the insurance Company name address and phone number in SOAPware to match the remit information will reduce errors on future remits from the same payer. (This will also change the payer information in patient insurance demographics tab)
Some payers may be contracted with different names for providers, groups, etc. and will not match exactly with the Pay To information as SOAPware settings and must be manually matched.The names listed include the names received in the 835 file and as seen on the printed remits.
4. Click the drop down arrow to select the appropriate group from the list.
The Remit View is a snapshot of claims and payments exactly as they are received in the electronic 835 file and are not editable from this view. To manually edit an adjustment, double click on the claim line. Edits will not change this snapshot.
If a claim line is shaded pink, the download failed to match the patient demographics or claim and must be manually corrected.This example claim failed to match because of the policy number was different than the one in SOAPware.
5. Click on the claim line to claim, View Remit Errors and Match to open Patient/Claim Match window.
The top section of the Match window payment details returned from the payer and the bottom section is patient account information in SOAPware. If the claim is matched, this window will open focused on that claim. Payer details show the claim was processed as secondary, and checking the Secondary Policy# confirms the numbers are different.
6. Expand to view claim details if needed, or verify claim is correct by checking Date of Service, Claim amount, etc. on claim line.
7. Match Claim and OK to match the selected claim with this remit. (Payment Details window opens.)
8. In payment details window, verify details are correct and Save Claim to save changes and remove error alert from the Remit View.
Some payers return patient names that do not exactly match the information in the SOAPware account. If a claim error is because of a Patient mismatch that patient and claim must be manually matched.
1. Type patient last name or the first 2-3 letters of the last name and press Enter on your keyboard. First name search is also available by typing first few letters and then press Enter on the keyboard. List of matches along with policy information is shown.
2. Find the correct patient in the list and Match Patient. (Payment Details window opens.)
3. Verify payment details are correct and Save Claim to remove error alert from the Remit View.
4. If unsure about a correct patient, expand to view claims that are currently pending insurance processing and in the Submitted status, or place a check mark in Show All Claims to view claims that are in the Processed status and after verifying the claim is a match, click the Match Claim button.
View Claim Alerts and Warnings
Payers will deny a claim for different reasons and automatically deduct the non covered amount from the billed amount on the remit. Warnings and alerts are added to the Remit View enabling users to review the claim, determine the next action, and write off the adjustment or Omit it from the Adjustment total, make corrections and resubmit the claim.
- Warnings (stop sign) are seen when a claim is in the Denied status as a warning to review and determine if an adjustment is needed or if a claim needs to be refiled.
- Alerts (yellow triangle) are seen when a payer initiated adjustment needs to be reviewed to verify the adjustment is correct. These alerts usually do not require action, only review.
Claims details in the remit view includes how the claim is processed (Primary or Secondary) and the claim status to determine the Next Action. (File Secondary, Crossover, Patient Responsibility or Refile)
- View Claim Errors button will list all claims for a selected claim showing with a pink background or showing a warning or alert. This will list all errors on the selected claim.
- Click OK to exit errors list.
- Click to expand the claim and view charge details or select the Expand All-View Detail button to expand all claims on the remit.
View Adjustment Reasons and Remark Codes in Remit View
4. After expanding to view details, hover mouse over the icon, Adj Codes or Remark Codes to view the description and determine if the adjustment(s) total needs to be edited. If no editing is required, close details and proceed to the next claim if needed.
5. If a claim fails to match, the payment amount will remain in the Remaining balance until matched and posted. Post Payment button will not be active until all claims are matched and Remaining Balance is zero.
6. If edits are required, double click the claim line to open payment details and edit.
Some adjustments are defaulted to Omit from the Adjustment Total and will have a check mark in the Omit box. These adjustments will not be deducted from the billed amount or the charge balance.
1. To Omit this adjustment from the adjustment total place a check mark in the Omit box.
2. To change the adjustment amount and include the new amount into the adjustment total, change the Adj Amount, remove the check mark and ESC to close the Adjust Codes grid.
3. To include the full adjustment amount in the adjustment total and deduct from the charge balance, remove the check mark.
When a claim with warnings is opened for editing, the warning is removed and replaced with a yellow alert reading 'Reviewed' to mark it as worked. After all errors have been removed from the remit and the Remaining Balance is zero, the Post Payment button is enabled.