One of the most important things in your practice is billing or invoicing timeously to ensure that your claims reach the medical aid in time for the next payment run. The easiest way to do this would be to submit your claims via EDI (Electronic Data Interchange).
Submitting claims through EDI means the claim goes directly into the scheme’s claims processing pool and does not still need to be manually processed by an agent at the scheme. These claims therefore hit the scheme immediately and are processed faster, resulting in a better cash flow for the practice. EG: A claim sent via EDI on a Saturday afternoon will be process for payment on the following weeks payment run, but a claim sent via email on the same day will only be processed for payment the week thereafter.
How to switch to EDI on smeMetrics
To make the switch from email to EDI submissions you need to go to settings/ My Business info and scroll down to the section called “My Medical Aid Claim Preference”. You need to change the settings from Email to EDI.
Once you have made the change click the save button, you will be logged out of the system in order for smeMetrics to make the change on the back end, simply log back in and you will now be able to sent claims via EDI
Claiming using EDI submissions
The important thing to remember when using EDI is that you need to make sure that you have the below information and that it is accurate otherwise your claim wont be submitted or will be outright rejected
- Patient’s Name
- Patient’s Date of Birth
- Dependent code for the main/principle member
- Dependent code for the patient.
To invoice claims using EDI you will follow the same steps as your regular invoicing Click here for info the only difference is that in your billing/invoices section you will now have a button that says “submit” instead of “mail” an additional button called “Claim History” and an additional column called “Claimed Date”
To check if your claim has been submitted successfully, click on claim history and the below screen will open up.
If you click on “Claim response you will get a more detailed response advising if the claim has been accepted, rejected etc
Full Acceptance :: Means that the scheme has accepted the claim but does not guarantee payment
Partial Acceptance :: Means that the scheme has accepted the claim but that it will be manually processed and does not guarantee payment.
Rejected :: Means the claim has been rejected.
Some scheme’s will give a more detailed message such as the example above.
If a claim is rejected due to ICD-10 code, BHF code, Date of Birth ect the system will advise of the rejection reason and you can amend the claim and resubmit.
Need Further Help from Our Team
You can either send an email with the description of your query to support@smemetrics.com, or you can book a training session with our team at https://www.smemetrics.com/demo/
