What are these enrollments I keep hearing so much about?
Enrollment is the process that allows a provider to inform a payer that they plan to interact with that payer electronically and submits provider demographic information to the payer in order to establish this electronic link. Payers can require providers to complete up to four types of enrollment:
- Electronic Eligibility: Providers can check the eligibility status of their current or prospective patients electronically via their clearinghouse.
- Electronic Institutional Claim Submission: Providers submit claims to payers electronically through their clearinghouse that they would previously have sent on a paper UB-04 form.
- Electronic Professional Claim Submission: Providers submit claims to payers electronically through their clearinghouse that they would previously have sent on a paper CMS-1500 or HCFA-1500 form.
- Electronic Remittance Advice (ERA): Payers send providers via their clearinghouse an electronic summary of their claim determination, both for payments or denials, in place of mailing the provider a paper Explanation of Benefits (EOB) file.
Do all payers require all four types of enrollment?
No, the majority of payers require enrollment only to receive ERAs in place of EOBs. These payers allow providers to submit both professional and institutional electronic claims without prior enrollment. However, it is still best practice for providers to contact a payer before submitting their first claim to that payer electronically. This is because payers request that providers supply basic provider demographic details so that the payer can create an out-of-network profile for this provider. These demographics include provider name, service location(s), pay-to-address, Tax ID, NPI, and taxonomy. Providers should contact each payer they plan to submit claims to in order to find out that payer’s required demographics.
How do I know which payers require which enrollments?
Providers can contact their clearinghouse or visit this free online resource and search for payers by name to see which enrollments they require.
Are all enrollments pretty much the same?
Far from it. Each payer falls into one of the following buckets in terms of what their enrollment process involves:
- Some payers require no enrollment. Hooray!
- Payers such as Cigna offer a simple enrollment process that a provider’s clearinghouse can complete without any input from the provider.
- Payers such as Magellan require the provider to complete and sign an enrollment form and return it to their clearinghouse, which will then forward the forms to the payer. Providers can obtain these forms from their clearinghouse or billing company. Payers can take anywhere from 24 hours to 30 business days to process these forms. Some payers in this group, such as Aetna, also require providers to sign up to receive claim payments via Electronic Funds Transfer (EFT) in place of paper checks in order to be able to receive ERAs.
- Payers such as Beacon Health Options (AKA Value Options) use third-party vendors including PaySpan and InstaMed to manage their ERA and EFT enrollments. These vendors require providers to complete an online EFT registration process in order to receive ERAs from these payers. Providers must complete this online registration themselves, as opposed to having their clearinghouse or billing company complete it. These vendors often will only allow registration once the payer in question has issued one or more payments to the provider.
- Payers such as Humana require ERA enrollment through their own website. These enrollments take only a few minutes but typically also require that the payer has already paid one or more claims to the provider before allowing enrollment.
Another way in which enrollments differ from payer to payer is the amount of time that the clearinghouse requires to prepare enrollment paperwork before the enrollment is ready for the provider’s attention. Some enrollments, such as Beacon Health Options, are ready for the provider’s attention immediately, whereas others such as Oxford can take up to a week just to prepare the paperwork before the provider can take action.
Sounds like a lot of work. How am I supposed to keep track of all of this?
Avea Solutions offers providers hands-on enrollment support to ensure successful enrollment with each payer. Avea completes as much of the enrollment process for providers as payers will allow, then guides the provider through the steps that must be completed by the provider themselves, such as signing forms or completing third-party vendor registrations online. Avea also tracks all initial enrollment statuses and notifies providers of any issues or updates.
How long does it take before I start getting ERAs?
- It takes anywhere from 21-60 days for an enrollment to activate once the record has been received by the payer.
- The time it takes to activate is affected by whether or not you've submitted claims to the payer before.
Will you tell me if an enrollment "breaks?"
- Unfortunately, AveaOffice isn't notified when an electronic enrollment is no longer working. We recommend you monitor, on a monthly basis, the percentage of paper EOBs you're processing so you know if there's a decline overall.
- You can use the Claim Payments Report to get the total number of payments received on paper by payer using the data output in the column Payment Source where the output is Manual.
- If you notice you're no longer receiving electronic EOBs, you can reach out to our team and we'll help troubleshoot the enrollment.
Are electronic enrollments worth the effort to set up when I have a good process for paper EOBS?
- Electronic enrollments are tremendously valuable to providers, and Avea recommends that providers complete the enrollments for every payer they submit claims to.
- The most common, and by far most important, enrollment type is Electronic Remittance Advice (ERA).
- ERAs replace paper EOBs and are transmitted directly from the payer to the clearinghouse and then to AveaOffice.
- AveaOffice matches incoming ERAs to claims submitted via AveaOffice automatically and without any human interaction needed. This not only saves the provider countless hours of manual effort; it also ensures that claim payments are posted in an accurate and timely manner. Without ERAs, it’s impossible to have a truly “clean” billing process.
- ERAs are stored in AveaOffice indefinitely, eliminating the need to organize and file paper EOBs in a manageable and HIPAA-compliant manner.
- Electronic claim submission and electronic eligibility verification are similarly beneficial for the provider in that they all improve the accuracy and efficiency of the claim submission process.