ECS refers to the process of electronically submitting healthcare claims to insurance payers or third-party administrators, replacing traditional paper-based methods. It streamlines the reimbursement process by reducing paperwork and improving efficiency.
A third-party entity that acts as an intermediary between healthcare providers and insurance payers. Clearinghouses receive, process, and transmit electronic claims data, ensuring compliance with payer requirements before forwarding claims for reimbursement.
A federal law enacted to protect the privacy and security of patients’ health information. ECS must comply with HIPAA standards to safeguard patient data during transmission and storage.
The electronic exchange of healthcare data between providers, payers, and other healthcare entities. EDI standards facilitate the seamless transmission of electronic claims, improving accuracy and reducing processing time.
The process of electronically querying payers to check the status of submitted claims. Providers use this feature to track the progress of claims, identify rejections or denials, and take necessary actions for resubmission or appeal.
A detailed report sent by insurance payers to providers outlining the status of processed claims and explaining reimbursement decisions. RAs provide valuable information, such as paid amounts, denied claims, and reasons for denials, facilitating accurate revenue reconciliation.
Instantaneous processing of electronic claims by payers upon submission, allowing providers to receive immediate responses regarding claim acceptance or rejection. Real-time adjudication minimizes claim processing delays and accelerates revenue cycle management.
The refusal of a submitted claim by a payer due to errors or inconsistencies in the data. Common reasons for claim rejection include missing information, invalid codes, or eligibility issues. Providers must address and rectify rejected claims to facilitate timely reimbursement.
The process of submitting a claim to a secondary insurance payer after primary payer adjudication. Providers utilize secondary claim submission to recover additional reimbursement for services not fully covered by the primary payer.
The electronic transfer of funds from insurance payers to providers’ bank accounts for claim reimbursement. EFT expedites payment processing, reduces administrative costs associated with paper checks, and enhances cash flow management for healthcare organizations.