Electronic claims are sent and received using the standard EDI X12 837 data format.
- This format meets HIPAA requirements for the electronic submission of healthcare claim information.
- Within the standard are two versions, 4010 and 5010. Version 5010 is preferred because it is newer and has more fields available.
- Each e-claim consists of loops, segments, and elements.
- The requirements for e-claims are different than the requirements for paper claims. Printing a claim does not represent what is sent in an e-claim. Likewise information sent in an e-claim does not necessarily print on a paper claim.
In dentistry most e-claims are sent to a clearinghouse before being sent to the insurance company. Some big payers, like Medicaid, do offer direct connections.
For troubleshooting, see Clearinghouse Error Messages.
For more technical information about what is sent in e-claims, see E-claims Complexities.
Clearinghouses differ greatly in size, infrastructure, and business model. Some are small and tend to serve a local geographic area or focus on customer service. Some are actively pursuing more direct connections with payers. Some clearinghouses are more accurately described as aggregators, having a direct connection to only a few payers and sending the bulk of their claims to another clearinghouse.
Other Clearinghouses and Aggregators:
Additional clearinghouses and aggregators that are known to work well with Open Dental.
Direct Connections to Payers
Most payers prefer to use clearinghouses so they do not have to maintain direct connections with thousands of dental offices. However, some do offer direct connections. To use Open Dental for direct submission, there is work involved including: contact the payer, get their implementation
guide, set up a partnership agreement, test, and finally upload
claims. We do not provide implementation details and leave it up to
individual offices. But it can still be useful for very large volume offices. The X-12 files will typically need to be manually uploaded to the carrier because there is
no standard for transport.
The carriers below are also known to accept
X-12 claims, but we have not had time to do any testing with them
yet. Remember that we have no timeline for this functionality and it
might never even happen.
- ACS - Handles claims for Medicaid of Georgia and a few other states. Testing phase seems to be long.
- Medicaid of NJ - Could take a few months since they require certification
- Medicaid of TX
Updating to 5010 Format
Clearinghouses began accepting the 5010 format on 1/1/2012. To use the 5010 format:
- Use version 11.1.16 or later (Inmediata users, use version 11.1.30 or later).
- Edit your Clearinghouse to use the 5010 format.
- Monitor your reports for dropped claims or other problems.
For information about rejections due to Billing Provider PO Box, see E-claims Complexities under the PO Boxes subheading.