Electronic Claims - TriZetto

Integrating practiceQ with TriZetto will allow you to submit claims to insurance without leaving your practiceQ account. Additionally, practiceQ will capture the EOB (Explanation of Benefits) from your payers as they become available and automatically allocate insurance payments to claims and appointments. TriZetto has a very extensive payers list and it's quite likely that all your electronic claims can be submitted through them.

At this time practiceQ does not offer support for secondary or institutional claims.

Before starting the integration process, we encourage you to become familiar with our Claims module. The following article will give you a thorough overview of how to create claims: How to Create a Claim

We don't charge fees for claim submissions, but there are fees you'd pay TriZetto. Please contact them for any questions related to their pricing.

Preparing Your TriZetto Account

Before connecting practiceQ to TriZetto, Secure FTP access needs to be enabled in your TriZetto account. Currently, this is done by contacting their support. Additionally, in order for practiceQ to receive insurance payment information and keep the claim status up-to-date, you will need to ask them to enable ERA and 277CA reports.

Here's a template email you can send to TriZetto.

It typically takes 24-48 hours for TriZetto to enable SFTP access, and they may give you instructions on how to enable ERA reports for each payer. Some payers require pre-enrollment, which will require you to submit a form. We recommend doing that as soon as possible because some payers take 30+ days to enable ERA reports.

IMPORTANT - Without an ERA setup between each of your insurance payers and TriZetto, claims will not be updated in the practiceQ system as they have no way to send us back the ERA. Contact TriZetto or the insurance payer for more info on setting those up.

Regardless of how long ERA reports take to be enabled, you can connect your practiceQ to TriZetto as soon as SFTP access has enabled. This will allow you to start submitting claims from your practiceQ account.

Connecting practiceQ to TriZetto

If you followed the instructions in the section above, you will receive an email from TriZetto containing your SFTP user name and password. Log into your practiceQ account and follow the steps below:

1. Navigate to "More > Settings > Integrations".
2. Select "TriZetto".
3. Enter the SFTP user name and password provided by TriZetto, and adjust the FTP Address if the one they provided is different than the default one. Then click on "Connect to TriZetto".

   

Once the accounts have been connected, you will be ready to submit your claims via practiceQ.

Submitting Claims Electronically

Once your claims are created by following the instructions in the article How to Create a Claim, the easiest way to submit them is by navigating to "Lists > Claims", selecting the desired claims, clicking on "Bulk Actions" and then on "Submit to TriZetto". It's a good idea to validate them first to make sure there were no obvious mistakes.

Note: The above screenshot says "Office Ally", with this integration it will simply say "TriZetto" instead.

Once the claims are sent, their status will immediately change to Submitted. From then on, their status will be updated automatically as we receive updates from your payers. The possible statuses are:

• Acknowledged: The clearinghouse (TriZetto) or the payer has received the claim submission successfully.
• Processing: The claim has been scrubbed and the payer has started to process it.
• Information Requested: The claim is being reviewed by the payer. If the status doesn't change in 10 business days, please call the payer directly.
• Pending: The claim is being reviewed by the payer. If the status doesn't change in a few days, please call the payer directly.
• Rejected: The claim has been rejected by the clearinghouse or by the payer. You can update the claim and resubmit it just like you did the first time.
• Denied: This indicated that the payer has processed the claim and denied payment. You will typically see the reason of denial when you open the claim. Contact the payer directly if the reason is not provided.
• Paid: The claim has been adjudicated and the payment has been sent.

Keeping Track of Payments

When practiceQ receives remittance reports from your payers, it automatically closes the associated claims and creates a payment record containing the EOB details. In order to find the payments, navigate to  "Lists > Claims > Payments". Notice in the image below how you can see the amounts for each claim, including the amount paid and the patient responsibility. We also show the line items for each claim and their respective amounts.

This page also allows you to enter payments manually, in case you work with a payer that doesn't provide ERA reports.

Invoice Automation Options

There are various options available for how our system treats posted insurance payments and the associated invoice (or lack of an invoice). These options can be accessed under  "Lists > Claims > Claim Settings > Other".

You would use these settings to automate client invoicing based on claim payments. The system can create or update invoices based on the client responsibility portion of claim payments.

When Claim Payment is Posted:

• Do Nothing
• Create Invoice And Do Not Sen
• Create Invoice And Send

When Claim Payment is Posted, and Invoice already exists:

• Do Nothing
• Update Invoice And Do Not Sen
• Update Invoice And Send

CAUTION: If you manually change the status of a claim to "Paid" it can also update associated invoices.

Notification

If you'd like to receive a notification when an invoice is updated by a processed ERA, this can be enabled under  "More > Settings > Notifications".