Home Forums Discussions Coding and Billing How to submit claims to a clearing house

We are starting to do in house billing due to some bad outcomes from outsourcing our claims. We are having problems with our clearing house recognizing our claims. It needs to be in a 4010 or 5010 format and we can not figure out how to send them that way. Does anyone know how this can be done? Any help will be appreciated. We are getting desperate. Tech guys that we have talked to have not been able to tell us what to do. Thanks in advance.

What PM/billing system are you using?

A lot of this depends on clearinghouse and PM. Some years ago I started with a PM (EZclaim) and clearinghouse (Office Ally) and claims were not going through. Each blamed the other. Ultimately, I gave up and made another choice.

The point is: Each clearinghouse has specific requirements and each PM has a specific way of meeting this. You need to talk to both. As I recall 5010 is a fairly standard format, but that's from several years ago. Talk to the PM first as to how to generate one of the formats, generate it, then check with the clearinghouse as to whether it works.

Let us know specifics because everyone is always interested in knowing what works and what doesn't. There are a lot of people using a lot of different PM's, some may know the answer already.

We are going through Availity clearing house. When we initially talked with AC about using Availity, we were told there would not be any problem. Since then, we have tried to submit test claims to them in every format and so far none have been accepted. We don't know what to do. We are going to be in a financial bind soon if we can't get this figured out. Tech people have all been busy and we can not get anyone to answer our calls or chats.
Any suggestions? I thought the 5010 was a standard format that everyone used.

OK, let me back up a half step.

First, I will make an assumption that you are using the Availity package. I put it that way because I believe Availity has a clearinghouse itself, but also has a PM.

The Clearinghouse simply takes the claims electronically and sends them to the payors. In essence it is the "internet connection." The Practice Management software (PM) is what converts the information from AC into how it needs to be translated for the payors, keeps track of what is paid, what is outstanding patient and insurance balances, ect.

Your issue is really with Availity. You pay for service. If they cannot walk you through successfully connecting up, move upline to a more senior person or let them know you will find someone else. Since you are using their package, they should be able to make it work.

We are only using the clearinghouse, not their PM package. We are trying to do it all inhouse as much as possible.

I don't THINK you can go straight from AC to a clearinghouse. It certainly cannot accept the remittances to let you know what cleared and what did not, and that is important.

How are you generating 5010 files? When I go to export, I get:


Now I know the options change based on the billing service (and this was set to my prior service (working from a backup), but I don't see a way to do 5010's

Wendell, thanks for your replies. We have the same screen and that is what we are having trouble with. We can't figure out how to convert to the 5010. We know we will have to input the remittances ourselves, but we have to have a way to get the claims to the clearing house. Urghhhhh.

I do not think AC creates a 5010 directly.

I believe you will need a Practice Management (PM) Program to do this. There are many out there, go to the admin section and interfaces then practice management to see your options.

Several issues you should look at.
One is whether you signed a contract with Availity as clearinghouse. Can you change if the PM requires another, or are you locked in for a year or such? Are you set up with them for the various contracts (filled out paperwork to make them your registered clearinghouse) If you have filled out the paperwork, you might consider a solution that continues to use them (see below)

Which programs connect with Availity (probably most, it's a big clearinghouse.) Another question is whether it may be easier to go with Availity's own PM.

What's the lag time to set up any PM you might choose. AC and MedFx take some time (weeks to months) to implement. Some of this time is the clearinghouse setup (they require their own specific clearinghouse, you would have to change.) Any program requiring a change in clearinghouse is likely to have some delay. This is where sticking with Availity if you have filled out the paperwork might be easier.

Will the PM you are looking at require double entry or can it take information directly from AC (most that are in the interface section should not require double entry). Does the program give you what you are looking for regarding reports.