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Start Billing 5: EDI Claim Submission

Jane has an EDI generation tool to help manage your claim submissions. An EDI file is sort of like an electronic version of a CMS1500 form. In Jane, you can select a bunch of claims you’d like to submit, and then download a batch EDI file for those claims that can be uploaded to a clearinghouse for submission.

Jane currently supports EDI files for four different clearinghouses: Office Ally, Claim.MD, TriZetto and Availity.

In this lesson we’ll cover the following claim submission topics:

If you have not done so already, please go through the US Insurance Set Up Steps first.

Uploading EDI files to your Clearinghouse

The EDI Files we generate in Jane can be submitted to one of the 4 clearinghouses listed below. You’ll need to login into your clearinghouse account to upload the files.

You can submit this EDI file to either:

Generating an EDI File for Claim Submission

To generate an EDI file for one, or more than one invoice,

  • Head to the main Billing tab > Unsubmitted folder
  • Select the claims you’d like to include in your batch. You can select claims individually by clicking on the line item, or you can select a batch by clicking “Select All” from the filter at the top.
  • You will see a yellow/orange “View/Submit Selected” button. Clicking this button will launch the pre-flight check page for all the selected invoices.

  • If a required field for EDI generation wasn’t entered in properly prior to pushing the Submit button (i.e. no diagnosis codes were entered), you will need to fix those areas before you are able to generate an EDI.

  • Check the red text for errors and click on the blue “Edit…” text to launch a new tab to fix these errors. Once these errors have been fixed, you will be able to hit the Refresh button to update the changes.

  • Once all the fixes are made, then you can generate your EDI file.

  • Click the blue Download button once to download one EDI file that includes all of these claims/dates of service and then upload this file to your clearinghouse account.

And voilà!

You can now submit this EDI file to your clearinghouse.

All submitted claims will now be moved from the “Unsubmitted” folder area, over to the “Submitted” folder awaiting payment.

💡Jane Tip: Don’t see the View/Submit Selected button after selecting your claims? If so, make sure you haven’t selected a claim with Unsaved Changes. You can filter your Unsubmitted folder for any claims that have unsaved changes (i.e. an additional diagnosis code added after the visit). If you find any, you can click the “Unsaved Changes” text in order to view the purchase and save your changes. Jane requires that you save any changes made to your claims before generating an EDI file to ensure the correct info is sent off to insurance!

Submitted Claims back to the Unsubmitted Folder

Jane will revert a submitted claim back to an unsubmitted claim if any changes have been made to the invoice after the submission process. This includes behaviours like: (1) adding or removing an adjustment, (2) adding, removing or changing the insurer, (3) adding or removing billing codes to an invoice (4) changing staff member associated with invoice (5) adding or remove tax from a purchase.

If you are ever unsure whether a particular unsubmitted claim had been previously submitted, you’ll be able to View the Invoice from the unsubmitted folder to find out.

From the invoice details, you’ll want to scroll to the bottom of the page where the invoice history is located. If the claim had been previously submitted, it will show up as previously being Submitted at a certain date, but then marked as unsubmitted at a later time.

In these cases, you’d want to reevaluate whether it is appropriate to regenerate a new EDI file (as changes were made to the claim details) OR if you just want to mark the claim as submitted.

Resubmissions & Corrected Claims

If you’re using Jane’s EDI feature to submit to a clearinghouse and you need some help resubmitting corrected claims, then please read on!

Scenario 1: Receiving a Rejection From Your Clearinghouse Scenario 2: Receiving a Rejection From a Payer

Managing Resubmissions & Corrected Claims

📘 Continue learning the insurance billing workflow in Start Billing 6 - Posting Insurance Payments