Your claims travel a bit before they reach their destination at the Payer. But here is the process and what happens along the way.
You type a claim into FastEMC on your computer. The claim is added to your next Transmission file. You connect to your clearinghouse/payer and upload the Transmission file Within a few minutes, they generate a report called a ANSI 997 or a File Acknowledgement Report. The file was run through a very basic edit to see if it was formed correctly. If rejected at this point, it never goes anywhere else, so your first report would indicate if it was accepted. This is an all or nothing step. If there is a problem, the entire file is tossed out.
Next the file is run past the full ANSI 5010 edits and an 277 report is generated that looks at each claim and gives you more detailed error messages. If the file does not meet the ANSI 5010 rules it can be rejected, entirely at this point. Individual claims can also be rejected. Any claims that do not pass this editing are not sent to the Payer's adjudication system at all.
If a claim got past this point as acceptable, it is sent to the Payer. The payer then adjudicates the claim, which means they pay it or reject it for incomplete data, or invalid coverage, etc. This information is reported on the ANSI 835, EOB or Remittance Report.
If you had claims paid, they will issue a check to the provider.
It is very important that you review the reports provided by your clearinghouse to insure that you catch any errors and make corrections in a timely fashion. We are always surprised to get a customer that calls to tell us they are not getting paid and a review of their reports indicates the files have been rejected over and over and they did not seem aware of this at all.
