Electronic Remittance Advice (ERA)

The Electronic Remittance Advice (ERA) menu provides the following functions for automated processing of electronic Explanation of Benefits (EOBs) from various insurance carriers:
The ERA Activity Log tracks every activity performed on each remit file, and the ERA Journal to Excel exports historical ERA file information to Microsoft Excel, including the total number of patient accounts on each remit.

You must follow the setup steps outlined below prior to using these menu functions.

Setup Steps
  1. Contact the insurance carrier to determine if this service is available and complete the necessary paperwork. NOTE: Not all states or areas provide electronic EOBs. You will need to contact the insurance carriers in your area to determine if this service is available. Each carrier will require your practice to complete paperwork in order to set up your account and assign passwords to access your files and test the process. The method of file transmission will vary from insurance carrier to insurance carrier. You should receive detailed instructions for downloading the electronic remits directly from the insurance carrier.
  2. If you are processing electronic remits for multiple carriers, create separate folders on the CGM webPRACTICE server under the REMITS folder, for each carrier. For more information on the REMITS folder see the REMITS section below.
  3. Complete the ERA Integration Setup for each insurance carrier based on the electronic form number submitted.
  4. Work with your insurance carrier to test the 'connection and download' process. Once you have successfully downloaded a file, you can proceed to use the ERA menu functions provided to process it.
REMITS
When CGM webPRACTICE was originally installed, a REMITS folder was created on the C drive of your CGM webPRACTICE server. If you elect to download electronic remits for multiple carriers, you will need to create separate folders under the REMITS folder for each carrier and download the files directly to the specified folder for each carrier. Please contact your IT/Hardware Specialist if you need help creating new folders. If you will be downloading electronic remits for only one carrier, the files can be downloaded directly into the REMITS folder.

As an alternative to the REMITS folder method, you can use the Upload Remits function to upload remit files directly within CGM webPRACTICE for the selected insurance carrier.

Steps for Processing Electronic Remit Files
  1. Import and print a copy of the EOB.
  2. Post the electronic remit file. You should NOT import any additional files until you have completed the following steps and balanced the EOB to the payment journal.
  3. Print the Payment Exceptions Report and manually post any exceptions. See the full list of the ERA Payment Exception Messages below, for assistance with resolving the issues.
  4. Print the Payment Journal and compare it to the EOB to ensure the totals match. If the totals do not match you should go through the report in detail and verify each payment on the EOB is also listed on the Payment Journal and that all the dollar amounts match.
DO NOT IMPORT OR POST ANY ADDITIONAL EOBS until you have balanced the Payment Journal to the EOB.

ERA Payment Exception Messages
Code ERA Payment Exception Message Description
1 Procedure not in open index-not posted Either a payment has been posted to the procedure or an exact match cannot be found (checking Date of Service, Equivalent CPTs and Modifiers). In either case, you must make the final determination on how to allocate the payment.
2 Unable to match Procedure/Procedure details A match could not be found for this date of service corresponding with this procedure code.
3 Billed amount doesn't match The billed (charge) amount on the patient's account does not match the billed amount reported on the remit. Verify the charge against the EOB; this payment will need to be reviewed and posted manually.
4 Insurance balance is zero There is no insurance balance remaining on the procedure, so the payment cannot be auto-applied. Review the account history and allocate/post manually if appropriate.
5 Amount paid is more than owing The payment reported by the carrier is greater than the amount still owed on the procedure. Verify the charge and any previously posted payments; the overpayment may require manual allocation or a refund.
6 Allowed amount doesn't match The allowed amount on the remit does not match the allowed amount calculated on the account. This is a warning (the item posts unless another exception occurred), but the allowed amount should be reviewed for accuracy.
7 Zero amount No payment amount was reported for the line item(s) on the remit. Review the EOB to determine why nothing was paid and post manually if needed.
8 Allowed Amt doesn't = calculated Pmt/Adj The allowed amount does not equal the payment plus the adjustments for the line item, so the amounts on the remit do not balance. Depending on system setup this is treated as a warning or an exception. Review the EOB and post the payment and adjustments manually.
9 Adjustment amount will create a credit Posting the adjustment will create a credit on the patient’s account.
10 Patient not found The patient account number on the remit could not be matched to an account. Verify the account/patient and post manually, or correct the account information.
11 Allowed amount equals zero The carrier reported an allowed amount of zero for the line item (for example a full denial or non-covered service). Review the EOB and post manually if appropriate.
12 Names do not match The patient name on the remit does not match the name on the account for the supplied account number. Verify this is the correct patient before posting manually.
13 This carrier is a secondary carrier The remit is from a carrier set up as the secondary (or later) payer on the account. Secondary/crossover payments are not auto-posted; review the EOB and post manually.
15 Contractual code same as billed amount The entire billed amount of the line item was taken as a contractual (CO) adjustment, leaving no payment. Verify the contractual write-off is correct and post manually.
16 Did not pay or allow for this item The carrier neither paid nor allowed any amount for this line item (the full amount was adjusted to patient responsibility or otherwise not covered). Review the EOB and post manually.
17 Missing details on Secondary payer Information required to post the secondary (crossover) payment is missing from the remit. Review the EOB and post manually.
18 Claim denied, can't identify The claim was reported as Denied at the claim level (835 claim status) with no line-level payment detail to identify how to apply it. Review the EOB denial and handle/post manually.
19 Comments An informational comment is attached to this line (for example an account note, a secondary adjustment, or "Other Adjustment 97 present"). This is a warning provided for the poster's awareness; the item posts unless another exception occurred.
20 Adjustments could affect amt pd The remit contains claim-level adjustments (CAS applied at the claim level, not to a specific service line). These can affect the amount paid/applied, so this is a warning - review the claim-level adjustments to confirm the posted amount is correct.
21 Payment is negative-post manually The remit reports a negative (credit) payment for this item, which cannot be auto-posted. Post the reversal/credit manually.
22 Pmt is greater than claim pmt-post manually The payment reported for the individual line item is greater than the total payment reported for the claim/check, so the amounts do not reconcile. Review the EOB and post manually.
24 Line items do not tally remit total The sum of the individual line-item amounts does not equal the total reported for the check/remit. Review the EOB to reconcile before posting.
25 Missing payment breakdown, contact CGM The remit is missing the payment breakdown needed to post the item automatically. If this recurs, contact CGM support with the ERA file for review.
26 Interest payment - not posted The line represents an interest payment from the carrier rather than a payment against a charge. Interest payments are not auto-posted; post manually to the appropriate account if needed.
27 No procedure included in EOB - not posted The remit line did not include a procedure code, so the payment could not be matched to a charge. Review the EOB and post manually.
28 Carrier no longer in effect for DOS The carrier on the remit is termed/inactive for the date of service on the account. Verify the patient's coverage for that DOS and update the policy or post manually.
29 Roll Up Claims must be posted manually The remit represents a "rolled up" (bundled) claim, which cannot be auto-posted. Review the EOB and post the bundled amounts manually.
 
Click the link for a pdf version of the ERA Payment Exception Messages.