Payment reports are our version of an Electronic Remittance Advice (ERA). This means you'll receive one of these helpful reports from the payer every time a claim is finalized and in this article, you will learn best practices for understanding the payment report you receive. Learning to read payment reports will be useful when adding/editing insurance payments, learning about your client's deductible, or learning about why a claim was denied. Once the payment report comes in, you'll be able to view the report in the Claim Details of the claim you've submitted, under the Payment Overview section.
Note: For more information on ERAs and how to enroll, please review this guide: Payment reports (ERAs)
Scenario 1: Paid
In this scenario, the claim has been successfully processed by the payer and paid. When the payment report comes in, an insurance payment is automatically created, allocating the labeled amounts and updating the claim to the paid status. If you need to manually add or edit an insurance payment, please review this guide: Adding an insurance payment.
Tip: Client Responsibility + Insurance Paid + Write-off = Total session fee (billed amount)
Scenario 2: Deductible
In this scenario, the client has not met their deductible and a payment report has come in updating the claim status to Deductible. When viewing the payment report, you'll see the Deductible Amount. This is the amount the payer would have paid if the client had met their deductible. This amount is now the client's responsibility and will be applied to their deductible. Please review this guide for more information: How to bill clients that have not met their deductible.
Tip: Client Responsibility + $0 Insurance Paid + Write-off = Billed amount (this will update the claim to Paid)
Scenario 3: Denied
In this scenario, the payer has denied payment for the submitted claim. It is always recommended to reach out to the payer directly regarding claim denials because the information shared with our clearinghouse can be very limited. When speaking with a representative, you'll want to reference the claim using the member's ID and the dates of service to get additional details on what caused the denial and how to correct the claim. Sometimes, payment reports will have exact reasons to the cause of the denial that can be seen by hovering your cursor over the ? as shown in the image below:
For more information on denied claims, please review this guide: What do I do if my claim is denied?