Basics of Electronic Claim Submission

Signing Up

To send electronic claims with your Stratford Software you must follow these steps:

1.        You must sign up with Medicare, Medicaid, and/or a clearinghouse

2.        You must submit a backup to Stratford so we can build transmission files for you, send test claims, and get you approved

Step One: Depending on which claims you wish to submit electronically you may need to contact your Medicare and/or Medicaid representative. They will provide you with sign-up registration papers for your ID and password. If you are going to send private insurance claims you must sign up with a clearinghouse. Some clearinghouses also accept Medicare and Medicaid claims and some will even print forms on paper for you. In most cases, Medicare and Medicaid claims are free if you transmit "direct." Most clearinghouses charge an initial sign up fee, a minimum monthly fee, and/or a per claim charge. Contact Stratford to find out which clearinghouses are accepting claims in your area.

Step Two: Stratford will build some files for you that tell the computer who to call and what to send. When you are approved for production, we will send a CD containing the needed files with instructions for loading the files onto your computer. We can also transmit the files directly to your computer or attach them to an email.

Transmitting Claims

The following steps will ensure trouble free transmission of electronic claims:

1.        Create claims just as you would if you were printing them on paper (see the chapter: Creating Insurance Forms)

2.        Transmit your claims

3.        Verify that the claims were received

4.        Print the claims on plain paper (if desired)

5.        Print any audit reports and delete any unnecessary files

Step One: See Creating Insurance Forms

Step Two: After the claims have been demanded or created, new selections will appear at the Accounts receivable (main) directory. These include something like:

9  You have 4 files that have not been printed/processed

10  You have 9 audit files that have not been printed.

Now you simply click on selection 9 or 10. Then a list of files will appear. For example if you choose 9 then the list of files will look something like:

M6R911.LST PRIVATE CARRIERS ECS(IMS) 456 PAGES

M6R511.LST 92 CMS-1500 PRIVATE PAY 1456 PAGES

M6R564.LST Medicare 21456 pages

Don't print/process any files        

You can click on any of these files for the Print/View/Erase menu to appear. From this menu you can select Transmit this File to send the file.

Step Three: Verification of claims is accomplished differently depending on the destination of your claims. For example, some clearinghouses like CareVU will send an audit report of your previous transmission during the current transmission of new claims. Northern California Medicare has a bulletin board that users can call to get the status of their electronic claims. Still others, such as Medicaid of California (Medi-Cal), transmit the audit report to you at the end of transmission. Some may require you to verify your transmission by telephone. You must determine what method your destination uses and verify that your claims were received before proceeding. If you ignore this step you will inevitably be forced to manually demand your claims and resubmit them. Stratford has no way to know when you transmit or if your transmission worked correctly. Stratford is not notified when there is a problem. Stratford depends on you, the client, to tell us when there is a problem.

Step Four: Once you have verified that your claims were received, you should load your printer with plain paper and print a copy of your claim forms on plain paper. See Printing Insurance for more information. You should save this plain paper copy until you receive payment on the claims. If for some reason the destination "loses" your electronic claims you can submit a paper copy from the plain paper version or use it to demand a new claim.

Step Five: After printing the claim forms you should also print the AUDIT files.

Remember, if you still have the original EDI "LST" transmission file, you can very simply retransmit the claims, without recreating the claims. We have clients who keep a backup of the "LST" files so they can easily retransmit.