About Claim Rejections
There are five steps involved in the claim process:
- Patient check-in
- Coding of diagnosis, procedures and modifiers
- Charge entry
- Claims submission
- Payment posting
When a claim is submitted from zHealth, claims go through three separate checks before reaching a payor’s internal adjudication system.
1. Formatting Review: When you submit a claim from your zHealth account, the claim goes to the clearinghouse - Office Ally. The clearinghouse checks for claim formatting rules. If there is missing or invalid information in the claim, the clearinghouse sends an error message to zHealth. You can view the error in the Billing Center. When this occurs, view the error report by the clearinghouse and make the necessary correction(s) in order to resubmit the claim.
2. Scrubbing: Next, the claim is scrubbed by the clearinghouse for coding and billing accuracy. If the clearinghouse identifies an error, an error report is typically created for a biller or the clinic staff and sent to the zHeathEHR system. You can view the error in the Billing Center for a given claim and correct it for resubmission.
3. Payor Review: Once the claim passes the scrubbing process, the clearinghouse sends it to the payor. The payer then reviews the claim based on the patient’s insurance plan coverage, contract with the provider, provider details, patient details, and more before forwarding it to the internal adjudication system. Any claim denials or rejections at this stage are reported via an Electronic Remittance Advice (or Explanation of Benefits). You will have to log in to your Office Ally account to check the errors.
1. Formatting Review: When you submit a claim from your zHealth account, the claim goes to the clearinghouse - Office Ally. The clearinghouse checks for claim formatting rules. If there is missing or invalid information in the claim, the clearinghouse sends an error message to zHealth. You can view the error in the Billing Center. When this occurs, view the error report by the clearinghouse and make the necessary correction(s) in order to resubmit the claim.
2. Scrubbing: Next, the claim is scrubbed by the clearinghouse for coding and billing accuracy. If the clearinghouse identifies an error, an error report is typically created for a biller or the clinic staff and sent to the zHeathEHR system. You can view the error in the Billing Center for a given claim and correct it for resubmission.
3. Payor Review: Once the claim passes the scrubbing process, the clearinghouse sends it to the payor. The payer then reviews the claim based on the patient’s insurance plan coverage, contract with the provider, provider details, patient details, and more before forwarding it to the internal adjudication system. Any claim denials or rejections at this stage are reported via an Electronic Remittance Advice (or Explanation of Benefits). You will have to log in to your Office Ally account to check the errors.
Note: zHealth software provides you with the ability to delete active claim unless its status is 8S. You can delete active claims that can be Primary, Secondary or Tertiary claims. This means you can delete active claims that have the following statuses - IS, RS, CE, 2S, 2E, 9S, and 9E.Related Articles
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