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RCM Insurance Enrollment Workflows

  • Updated

In this article, you'll learn about:

Insurance Enrollment 4-Step Process

  1. Setting up a ClaimMD (subaccount)
    1. A Support or Customer Success Manager (CSM) sets up a ClaimMD user account for a specific medical practice or billing team.
    2. This account is a "subaccount" under the larger ClaimMD system, meaning it's tailored to a specific practice, with individual providers under it by their NPIs.
  2. Verification Call from ClaimMD
    1. Once the account is set up, ClaimMD makes an automated verification call to
      the provider’s phone number.
    2. This is used to verify the identity of the provider/practice.
    3. The verification pulls data from the NPPES database (which is where all provider credentials are stored nationally). You can see provider records here.
  3. Credentialing with Payors
    1. Before a provider can accept insurance from different health plans (like BCBS, Cigna, Medicaid, etc.), they must go through a process called credentialing.
    2. This means the provider needs to apply and get approved by each individual insurance company.
    3. To do this, the provider or their biller needs to visit each insurance company's website to find out their enrollment process and complete it.
  4. Claim Submission & Remittance
    1. After finishing steps 1-3, the practice can start submitting insurance claims through the Revenue Cycle Management (RCM) system.
    2. At first, they’ll receive paper checks and paper remittance (EOBs) from the insurance companies.
    3. Eventually, the provider or biller must notify each payer that they want to switch to electronic remittance.

Who is Responsible for Each Activity During Enrollment

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Lifecycle of a Claim

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Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is a statement from a health insurance company after a claim is processed. It details the amount billed by the provider, the portion covered by insurance, and any remaining patient responsibility.


A typical EOB includes:
1. Patient Information: Patient name or the name of the covered individual.
2. Provider Information: The doctor, hospital, or clinic that provided the service.
3. Date of Service: When the medical care was given.
4. Service Description: What procedures or services were provided.
5. Amount Billed: What the provider charged.
6. Allowed Amount: What insurance considers a fair cost for the service.
7. Insurance Payment: What insurance paid.
8. Patient Responsibility: What patient may owe (copay, deductible, coinsurance).
9. Reason Codes: Short codes or explanations for any adjustments or denials.

Example:

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Electronic Remittance Advice (ERA)

An ERA is the electronic version of an Explanation of Benefits (EOB). It’s sent by an insurance company to a healthcare provider. It details how claims were processed, including:
1. What was paid
2. What was denied or adjusted
3. What the patient may owe

It helps automate and simplify claim posting into the provider’s billing system.

How EOBs and ERAs Work Together

1. The insurance company processes a claim.
2. It sends an ERA with the details.
3. It issues an EFT to pay the provider.
4. The provider matches the ERA to the EFT to reconcile the payment.

Supporting Help Center Articles for Reference

Submitting claims

Receiving Electronic Remittance Advice (ERA)

Managing Electronic Funds Transfers (EFT)

 

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