Have some specific questions about our ERA Management Tool that weren’t answered in our Posting Insurer Payments With ERAs guide? If so, you’re in the right place!
- Does this feature only work for particular clearinghouses?
- Can I get my clearinghouse to automatically send ERAs to Jane?
- What is the Response Received folder? When does a claim move to Response Received?
- Where do I upload my ERAs?
- What does Unlinked mean, and why is my claim response Unlinked?
Uploading an ERA
- What happens if we upload an ERA file we have already manually reconciled in Jane?
- What happens if we upload an ERA that includes claims responses from multiple insurers?
- What types of ERA files are not supported?
- Can I delete a remittance?
- How do I manage claim reversals/reversals of previous payments?
- What happens if I get a claim response for a claim that has a previously entered EOB?
- What if the insurer states a portion of the visit is the patient’s responsibility, but it isn’t a copay, coinsurance, or deductible?
- How are Claim Responses organized/filtered by default in a given remittance?
- What is a Provider Level Adjustment? What is an Overpayment Recovery?
- How do I download ERAs from Office Ally?
- Office Ally gave me two remittance files. Which one should I upload to Jane?
- How do I download ERAs from Availity?
- How do I download ERAs from TriZetto?
- How do I download ERAs from Claim.MD?
- How do I download ERAs from Waystar?
What is a Remittance?
A paper or electronic transaction that includes adjudication information (who is paying for what) and payment information for one or more claims. A remittance includes a single payment amount - and parts of the payment amount are assigned to some but not necessarily all claims responses included in the remittance.
A remittance usually has many claim responses.
In short, a remittance that is external (i.e. a piece of paper). Some clearinghouses will use the term *Readable Remittance*. Paper remittances have to be recorded manually in Jane.
See the following guide for more info: Posting Insurer Payments for Paper Remittances
Electronic Remittance (ERA)
A remittance in the form of a 835 transaction. Basically one big text file that different systems - like Jane - can process to make it much easier for clinics to post payments.
What is a Claim Response?
A claim response is our Jane term for the adjudication and payment information for a single claim. A remittance usually has many claim responses.
All claim responses under a remittance show in a list when viewing a remittance:
And when you View one of the claim responses, you’re brought to a page with the adjudication info for that claim (ERA details), as well as the Jane EOB screen:
Does this feature only work for particular clearinghouses?
Although we only support electronic claim submissions to four clearinghouses (Claim.MD, Office Ally, Availity & TriZetto), our ERA Management Tool will work for remittances from any clearinghouse or insurer portal!
Can I get my clearinghouse to automatically send ERAs to Jane?
If you’re using Claim.MD as your clearinghouse, yes! Check out our Integrated Claims with Claim.MD beta to learn more.
If you’re working with another clearinghouse, you can manually upload ERAs to Jane.
What is the Response Received folder? When does a claim move to Response Received?
The Response Received folder was introduced as part of our ERA Management Tool workflow.
This folder holds all of the claims that have been submitted and are linked to a claim responses that are still Awaiting Review. All the claims in this folder are waiting for your review - which can be done through the Remittances tab.
A claim will move to Response Received in two scenarios:
- If you upload a remittance and Jane automatically links one of the claim responses in the remittance to that claim.
- If you manually link a claim response to a claim on your account.
Once you apply the EOB/payment in the claim response, the claim will move out of the Response Received folder (i.e. if everything billed has been accounted for after the EOB, it’ll move to the Approved folder).
Where do I upload my ERAs?
In the Remittances folder, which can be found in the Billing tab.
What does Unlinked mean, and why is my claim response Unlinked?
A claim response will start as Unlinked if Jane isn’t able to automatically link it to a claim on your account. This usually only happens if you didn’t submit the claim through Jane!
If you’re working with an Unlinked claim response, you can manually link it to a claim on your account by using the search bar in the claim response view. You can use the details found at the top of the claim response to help determine which claim to link!
If you accidentally link a claim response to the wrong claim, you unlink it by clicking the broken chainlink icon.
Uploading an ERA
What happens if we upload an ERA file we have already manually reconciled in Jane?
You have two choices!
- First choice: If you’ve already manually posted the entire payment, then you can simply delete the ERA file you’ve uploaded!
- Second choice: If you’ve manually processed EOBs under claims for some but not all claim responses in the remittance, then you can use the ERA workflow to process the remaining EOBs, and manually mark the redundant claim responses as ‘Reviewed’.
Manually marking a claim response as ‘Reviewed’ does not apply an EOB or payment to the linked claim - it just tells Jane you’re done with that claim response. Since you’ve already applied an EOB and payment to the claim, there’s no need to apply another EOB through the claim response!
What happens if we upload an ERA that includes claims responses from multiple insurers?
Sometimes you might be managing the same insurance company as two different insurers in Jane. Or, a big insurance company might have multiple entities that you submit claims to, but just a single place where money is sent from, which causes you to create multiple insurers for each submission entity.
In both of these cases, Jane has you covered.
If you upload a remittance with claim responses that are automatically linked to claims from multiple insurers in your Jane account, then Jane will ask which insurer you’d like to record the overall payment under in step 1. You’ll be able to apply the payment to all claims in the remittance, so just choose the insurer you’d like to have the payment under for your records.
What types of ERA files are not supported?
Electronic remittances can come in a ton of different file extensions. Oddly enough, every clearinghouse tends to have a different default ERA file extension. But that’s okay, because Jane supports many different files extensions.
The only file types we don’t support are PDF, ZIP, and Spreadsheets (CSV or XLSX). Electronic remittances typically don’t come in any of these file types anyways, and your clearinghouse will definitely have a different file option.
Can I delete a remittance?
Yes - but only if all the claim responses in the remittance are still Awaiting Review.
If you’ve uploaded an ERA, and realize afterwards that you’ve already posted that payment manually as a paper remittance, then you can select that remittance in the Remittances list, click the Selected dropdown, and choose the Delete button.
Note that you can only delete remittances that are Awaiting Review or Unlinked. You can’t delete remittances if they are In Progress or Approved (since that means you’ve posted some or all of the payment)!
How do I manage claim reversals/reversals of previous payments?
To fully answer this question, we need to really dive deep into an example. But before we do that, here’s the TL:DR of how to manage a claim reversal:
If the insurer is changing how they originally adjudicated a claim, then you should get two new claim responses in the remittance:
- a claim response that reverses the previous claim/payment (Reversal). This claim response typically includes all negative amounts to reverse the previous allowed, paid, and patient amounts!
- a claim response that states the new total adjudication amounts of the claim. “Total” meaning if an insurer paid you $20 originally, and then decides that they will actually be paying you $30, the new total amount on the claim response would be $30.
To manage these new claims responses, you’ll want to:
- Manually mark the reversal claim response as Reviewed (do not apply an EOB in this claim response - just acknowledge that you’ve seen it!).
- Follow the typical “additional EOB” workflow for the new claim response. Applying the EOB for the adjusted amounts will apply any additional insurer payment in this remittance, or it will create a credit for previous insurer payment(s) depending on if the insurer is sending more money or telling you they paid you too much before.
Okay, let’s walk through an example together in the following video tutorial. In this example, the insurer did not pay us the first time we submitted the claim because we forgot some key information. However, after we re-billed the claim, they paid!
Managing Claim Reversals/Reversals of Previous Payments
What happens if I get a claim response for a claim that has a previously entered EOB?
First off, when we say “claim that has a previously entered EOB”, we mean that you’ve already applied an EOB to that claim in Jane. In other words, a claim that has already had at least one response from the insurer.
When you view a claim response that is linked to a claim that has a previously recorded EOB, the new claim response will still start in Awaiting Review (just like all other claim responses!). Because an EOB has already been applied to this claim, Jane will not automatically pre-fill the EOB screen with the new response values when viewing the new claim response.
Instead, you will see the “additional EOB” screen; Where the totals from the previously entered EOB are displayed, and are greyed out.
Jane doesn’t pre-fill the EOB screen with the values from the new claim response so you don’t lose any previous EOB information!
That said, you still can make adjustments to the previously entered EOB when reviewing the new claim response - you’ll just need to make these changes manually.
Here are some examples of when you’d likely need to adjust the previous EOB to reflect the newest response from the insurer:
- you received more money from insurance
- the insurer is recovering an overpayment from the previous response
- the patient responsibility has changed
If you need to update the EOB, then you can click Edit Existing Amounts button for each procedure that requires a change.
When you press that button, you’ll be able to adjust any of the procedures values as needed. Once you’ve updated all your procedures, hit Apply Changes and you’re done reviewing the claim response!
More on the recording additional insurer payments can be found here **
What if the insurer states a portion of the visit is the patient’s responsibility, but it isn’t a copay, coinsurance, or deductible?
Jane has you covered!
How are Claim Responses organized/filtered by default in a given remittance?
Jane groups related claim responses together! If there is more than one claim response for the same claim (i.e. if there is a claim reversal), then they will be next to each other in the list.
What is a Provider Adjustment? What is an Overpayment Recovery?
When an insurer processes a claim, they typically make adjustments to each procedure. Adjustments made to procedures are commonly referred to as service adjustments. Each service adjustment is accompanied by a dollar amount and a reason code. Adjustments essentially explain why an insurer isn’t reimbursing you for the full amount that you billed. The most common examples of service level adjustments are related to contractual obligations (i.e. CO:45 — billing more than your contracted rate), and patient responsiblity (i.e. PO:1 — which means the amount is going towards the patient’s deductible).
In addition to service adjustments, insurers will occasionally adjust the total payment amount of a remittance to account for a reason that’s unrelated to any of the claims or procedures in the remittance. Adjustments made to the entire remittance (not made to one specific claim or procedure) are called provider adjustments.
If a remittance has provider adjustments, Jane will display them in the top right hand corner of the remittance view. You’ll see the type of adjustment, the amount (positive or negative), and the reference number the insurer has assigned to it. If you have any questions or concerns about a particular provider adjustment, it can be helpful to use that reference number when following up with the insurer.
Here are some common examples of provider adjustments that you might see on your remittances:
- 50: Late Charge (late claim filing penalty)
- 51: Interest Penalty Charge (interest assessment for late claim filing)
- IP: Incentive Premium Payment (one of the few positive Provider Adjustments you can receive)
- WO: Overpayment Recovery (the recovery of an overpayment from a previous remittance)
The most common — and most difficult to reconcile — provider adjustments are Overpayment Recoveries. Overpayment Recoveries occur when an insurer reviews their previous payment records and finds that they paid you too much for some previously adjudicated claims — claims that have likely been sitting as Paid and Approved in your Jane account for quite some time.
When an insurer identifies an overpayment, they will send you a notice that explains the overpayment amount (i.e. why you should have been paid less, which claims were overpaid etc). The notice will state the recovery amount, and will give the option to either return the money (i.e. write them a check), or if you do nothing, have them take the amount out of a future remittance.
Like most clinics, you’ll most likely choose the latter (although you could make things easier on your bookkeeper by taking the former option).
If you choose the latter, then you’ll eventually receive a remittance with an overpayment provider adjustment that reduces the total amount of the payment.
For example, let’s say that your remittance includes responses for 5 claims, and sum of the paid amounts for all 5 claims in $500. If the insurer previously overpaid you by $100 in a payment from 2 months ago, then you’ll only receive a payment of $400 with this remittance.
So, when you review your last couple responses, you won’t have the available funds (the remaining $100) to apply. The remaining funds that you need are from the previous overpayment in your account — a payment you likely recorded and applied months ago! The insurer is basically saying “apply the $100 we accidentally sent you months ago — money that’s probably applied to another patient’s claim at the moment — to pay for the remaining claims in this remittance”.
To find that $100, you’re going to have to reference the notice the insurer originally sent you, because the new ERA (with the Provider Adjustment) doesn’t tell you which claims were previously overpaid.
Once you find that $100, you’ll need to manually apply it to the remaining claim responses.
How do I download ERAs from Office Ally?
For full instructions on how to download ERAs, check out Office Ally’s User Manual - Page 15
- Click on Download EOB/ERA 835.
- Select a date on the calendar.Pink dates are days that have pending ERAs.
- Click the View link in the Download/View column next to the ERA file you wish to download. This will download the zip file which contains both the actual 835 file and a readable text version (txt) of the ERA.
You’ll need to upload the 835 file to Jane. Jane can’t process the readable text version!
Office Ally gave me two remittance files. Which one should I upload to Jane?
Download the 835 file. The txt file is the paper remittance.
How do I download ERAs from Availity?
Head into your Claims & Payments folder, and select the Remittance Viewer. You’ll be able to download remittances on the next screen!
If you are having trouble locating your ERA’s in the correct format, you may need to enroll first. Below are some steps to walk you through the enrollment process.
You can start the enrollment for ERAs/EFTs by navigating to My Providers > Enrollment Center > Transaction Enrollment. From here, select Enroll > Enroll a Provider.
If you would like your ERAs to be forwarded to another Clearinghouse besides Availity, make sure to check the box after selecting your Organization that states “Forward ERA files to another Clearinghouse”
The ERA files will now be delivered to your FTP mailbox located under Claims & Payments > Send/Receive EDI Files > Receive Files.
How do I download ERAs from TriZetto?
You can download new remittances in a folder in your account call Remits!.
We’re sorry this is so short! The TriZetto team doesn’t have any public resources available for downloading ERAs from their system that we can share here. They recommend that you go to the Resources tab in your account, and click Help Videos or Online Help. Both of these options have ERA-related content.
How do I download ERAs from Claim.MD?
Select View ERA which can be found under the Claim Menu. Next, select all the ERAs you haven’t processed yet (you can select multiple in one go!). The last step is click the Select Action dropdown, and choose the Download Selected 835 option.
How do I download ERAs from Waystar?
Although we don’t explicitly support electronic claim submissions to Waystar, some Jane clinics continue to successfully use it for their insurance billing needs.
Here’s how you can download a remittance from Waystar:
- Head to your Remits tab and click Payments.
- Choose your remit, click the dropdown arrow, and select Download.
- A new Downloads screen will appear. You’ll want to click Go To Downloads.
- Lastly, head to the Downloads area in the Remits tab, and click the dropdown beside the remittance. This will download the ERA onto your device!