Claim Issues: Problems with Claims and Enrollments

Why are claims being acknowledged by the payer but not processed further?

Answer: Before troubleshooting, check the source line underneath the status message on the Status tab:

• If the source tag reads from Claim.MD: The claim has only been received by our clearinghouse (Received by clearinghouse (Claim.MD)) and has not yet been delivered to or acknowledged by the insurance payer.
• If the source tag names the payer (e.g., from Aetna or from BCBS): The payer has received the claim on their front end, but it may fail to progress to adjudication due to:
  • Enrollment Linking Issues: The provider's National Provider Identifier (NPI) is not correctly linked in the payer's system for claim acceptance. Without proper enrollment, claims are acknowledged but not processed.
  • Front-End Payer Rejection: The claim was rejected at the payer's intake portal due to mismatched demographic or policy data before entering formal processing.

Recommended Steps:

1. Check the Status tab event log to confirm whether the acknowledgment came from Claim.MD or directly from [Payer Name].
2. If the issue persists or an official payer rejection is unclear, contact support@sessionshealth.com. We can work with the clearinghouse to verify provider enrollment details and claim routing.
3. In some cases, you may need to contact the payer directly with the claim details to confirm why their front-end system has not moved the claim to processing.

How can a provider resolve issues with missing ERA (Electronic Remittance Advice)?

Detailed Answer: Missing ERAs can occur when multiple accounts are associated with the same NPI and Tax ID combination in our clearinghouse or if ERAs are being routed to a different clearinghouse. Either of these situations leads to conflicts. Sometimes ERAs have been received but have not posted to Sessions Health.

Steps to Resolve:

1. Contact support@sessionshealth.com. Sessions Health can assist in investigating missing ERAs by providing us with the the following details:
   • Check Number
   • Amount
   • Date

If the ERAs are not with the clearinghouse, we may need to conduct further investigation including:

1. Identify Account Conflicts: Determine whether the provider’s information exists in other accounts. Use logs or direct contact to verify.
2. Delete Duplicate Accounts: Request that the other account remove the provider’s NPI and Tax ID combination to eliminate routing conflicts.
3. Escalate If Needed: If the other account does not act, escalate the issue to the payer or clearinghouse for manual intervention.
4. Ensure Correct Enrollment: Verify that the provider is enrolled in ERA under the correct account for the specific payer.

What steps should be taken if EDI enrollment confirmation is received, but errors persist?

Answer: EDI (Electronic Data Interchange) enrollment confirmations indicate that a provider can start submitting claims. However, errors can persist if:

1. Enrollment is Misconfigured: Despite confirmation, the enrollment may not be fully activated in the payer’s system.
2. Packet ID Mismatch: The provided packet ID should match the payer’s enrollment records.

Recommended Actions:

• Contact support@sessionshealth.com. We can work with the clearinghouse to take the provided packet ID and cross-check enrollment status with the payer.
• Confirm that the enrollment details (e.g., NPI, Tax ID, and address) match the approval letter.
• Troubleshooting may also require the customer to communicate with the payer’s support team to trace any missing steps or identify errors.

How long do claim submission enrollments typically take?

Answer: Enrollment timelines can vary depending on the payer’s processing systems. Confirmation emails usually suggest waiting at least three business days after receiving the enrollment approval. However, delays may occur due to:

1. Payer-Specific Policies: Some payers take longer to activate enrollments.
2. System Conflicts: Older accounts with overlapping NPIs or Tax IDs can delay processing.

Next Steps:

• Three business days after the enrollment notification has been received, if you are still unable to submit claims, follow up with the payer using the provided packet ID.
• Contact support@sessionshealth.com if you need additional support.

Can a provider enroll under multiple accounts for the same payer?

Detailed Answer: Providers cannot enroll under multiple accounts for the same payer using the same NPI and Tax ID. Doing so leads to routing conflicts, where ERAs and claims are directed to the wrong account.

Resolution Process:

• Identify the account where the provider was first enrolled.
• Confirm whether ERA enrollments were attempted in other accounts.
• Ensure the original account is updated or cleared to avoid further conflicts.
• Coordinate with the payer to redirect remittances to the correct, active account.

By following these guidelines and maintaining clear communication with payers and Sessions Health, providers can address common issues with claims and enrollments more effectively. Always keep documentation, including packet IDs and enrollment confirmations, readily available for reference during troubleshooting.