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The Plan Maintenance - ERA tab allows you to control how certain ERA (electronic Remittance Advice) functions will be handled.
Modifier to Ignore in the ERA File
Modifier 1
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ERAs are posted against charges by matching Date of Service, Procedure Code, Modifier(s), and Charge Amounts. Certain carriers are inserting a modifier on certain charges within their own processing system and returning that modifier in the ERA.
Enter the modifier to ignore in the ERA so that payments can be matched against charges.
Currently, this is only the AA Modifier for Cigna.
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Late Filing
Adj Type
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If a claim is filed late to Medicare, there may be a fee for filing late. The fee is deducted from the payment but is not the patient's responsibility. In order to get the ERA to "balance" between payment to the provider, contractual write-offs, and patient responsibility, the late filing fee is returned as an adjustment on the ERA.
Enter / Select the adjustment type that represents the adjustment for Late Filing Fees on a claim.
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Adjustments
Post Adjs from ERAs for this Plan (Primary Level)
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Indicates if adjustments in the ERA File(s) should be taken on primary claims.
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Post Adjs from ERAs for this Plan (Other Levels)
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Indicates if adjustments in the ERA File(s) should be taken on non-primary claims.
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Post Timely Filing Adjustment (AMT*KH)
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Indicates if a timely filing adjustment reported as AMT*KH should be posted. Some payers are reporting the timely filing adjustment in multiple places in the ANSI File and the ERA processing was taking the adjustments multiple times.
Do not set this unless instructed to do so by MedSuite Support.
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Calc Approved from Adjust if not Reported as AMT*B6
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Indicates the approved amount should be determined by subtracting the adjustment from the billed amount of if the approved amount is reported in the ERA.
The posting rules (below) are generally based on the approved amount. As a result unreported approved amounts could be seen as a denial by the ERA program. This feature handles this issue.
Do not set this unless instructed to do so by MedSuite Support.
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Posting Rules
Under-Payments
Underpayments fall into the following categories:
1. Approved equals Allowed, but Payment is Zero (Zero Payment)
2. Approved is less than the Allowed (or Expected) by
a. A percentage
b A dollar amount
3. Approved equals zero (Denials)
When one of these conditions occurs, MedSuite can be configured to take an action:
1. Post the Payment
2. Post the Payment, but give a Warning
3. Do not Post the Payment and put a Message on the Error Report
Zero Payment
Action
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Action to Take on a Zero Payment
| • | Do not Post and Report an Error |
| • | Post and Report a Warning |
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Status
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Status to set on the Payment when a Zero Payment occurs:
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When the Approved is Less than the Allowed by a Percentage
Percent
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Percent difference considered "less than"
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Action
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Action to Take on a when "Less Than"
| • | Do not Post and Report an Error |
| • | Post and Report a Warning |
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Status
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Status to set on the Payment when "Less Than" occurs:
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When the Approved is Less than the Allowed by an Amount
Amount
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Amount difference considered "less than"
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Action
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Action to Take on a when "Less Than"
| • | Do not Post and Report an Error |
| • | Post and Report a Warning |
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Status
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Status to set on the Payment when "Less Than" occurs:
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When the Approved is Zero and the Payment is Zero (Denials)
Action
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Action to Take on a Denial
| • | Do not Post and Report an Error |
| • | Post and Report a Warning |
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Status
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Status to set on the Payment when a Denial occurs:
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**Note - these rules only apply to level one Claims.
Special Procedure Rules
Sometimes, charges are billed to carriers that are not expected to be paid. This is often due to a desire to bill all carriers in the same way while acknowledging that the contract often vary. For example, some practices bill the Extreme Age Modifier (99100) to Medicare which does not pay for Extreme Age. The Special Procedure Rules allow the practice to accept and post these denials while not accepting other denials (above).
Procedure
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Enter / Select a procedure for which denial will be accepted.
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Post Denial
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Indicates if the Denial will be Posted
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