At Claim.MD, it's not uncommon for users to see an ERA (Electronic Remittance Advice) available under the "View ERA" section, but not see it reflected in the claim's payment history. This can be confusing—especially when the payer has clearly issued payment, yet the claim appears unpaid in the system. This article explains why this happens and how to interpret these situations. Understanding the Role of REF 6R (Charge ID) Each service line on a healthcare claim is assigned a unique identifier known as the REF 6R or Charge ID . This number is crucial because: It uniquely identifies a specific charge on a claim. It is used by payers when sending ERAs to match payments back to the original claim data. It is especially critical for automated payment posting and claim reconciliation. For direct data entry through Claim.MD, the system typically generates a well-structured and

Occasionally, adding documents such as a Member/Insured ID Card, Payer Explanation of Benefits (EOB), or similar documentation to an existing support ticket is required. This step aids in verifying Payer ID Numbers, a standard part of our procedure, or fulfilling other verification purposes. Steps for adding a document to an existing ticket: Scan the document, to create a PDF document for attachment. IMPORTANT! When scanning a card like a Member/Insured ID Card, you must scan both the front and back of the card.  Click on Support Tickets in the left menu.  Find your existing ticket in the Support Tickets page. Click the paperclip icon on the bottom left, select Choose File   , select the file on your drive, and click   Attach .  After attaching the document and entering your message, click the REPLY button.

obligation with respect to claims processed on behalf of your benefit plan. Start: 01/01/2000 N26 Missing itemized bill/statement. Start: 01/01/2000 | Last Modified: 07/01/2008 Notes: (Modified 2/28/03, 7/1/2008) Related to N232 N27 Missing/incomplete/invalid treatment number. Start: 01/01/2000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03) N28 Consent form requirements not fulfilled. Start: 01/01/2000 N30 Patient ineligible for this service. Start: 01/01/2000 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03) N31 Missing/incomplete/invalid prescribing provider identifier. Start: 01/01/2000 | Last Modified: 12/02/2004 Notes: (Modified 12/2/04) N32 Claim must be submitted by the provider who rendered the service. Start: 01/01/2000 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03) N33 No record of health check prior to initiation of treatment. Start

trends in resubmitted claims. Helps providers enhance billing accuracy and reduce claim denials. Report options: User, Claim Group, Time Frame. Age of Billing This report tracks the number of days between the date of service and the last claim submission. Used to identify submission delays and optimize claim processing times. Report options: Claim Group, Time Frame. Payments / Adjustments This report provides details on payments and adjustments applied by payers to submitted claims. Includes information on adjustment and denial codes. Useful for identifying claim adjustments and improving reimbursement accuracy. Report options: Claim Group, Time Frame. Time Till Payment This report measures the time it takes for claims to be processed and paid. Displays the number of days between claim submission and ERA receipt. Helps providers monitor payer processing times and address payment delays. Report options: Claim Group, Time Frame. Patient Demographics This report provides a visual representation (e.g., a map

The Manage Claims page highlights claims requiring attention.  Click on Manage Claims in the left-hand navigation menu. Graphs Recent Uploads Graph The Recent Uploads graph displays claim activity over the past seven days , grouped by status. It helps users quickly assess recent claim submissions and their outcomes. Users can click on each category in the graph to view a filtered list of the associated claims: Rejected claims Transmitted claims Pending Approval Deleted claims Recent Transmits Graph The Recent Transmits graph shows claim transmission activity over the past 30 days . It provides insight into how many times claims were sent electronically to payers, helping users identify submission patterns and potential follow-up needs. Transmitted: The claim was sent electronically to the payer. Note: This status does not confirm the payer received the claim—only that it was submitted. Re-Transmitted: The claim was sent electronically more than once to the

Payer Specific Bill ID/Submitter ID This payer requires a payer assigned ID number. This value can be sent in block 33b, bill_id Loop 2010AA, REF02, REF01=G2. 

not an eligible dependent. Start: 01/01/1995 | Last Modified: 03/01/2018 33 Insured has no dependent coverage. Start: 01/01/1995 | Last Modified: 09/30/2007 34 Insured has no coverage for newborns. Start: 01/01/1995 | Last Modified: 09/30/2007 35 Lifetime benefit maximum has been reached. Start: 01/01/1995 | Last Modified: 10/31/2002 39 Services denied at the time authorization/pre-certification was requested. Start: 01/01/1995 40 Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 07/01/2017 44 Prompt-pay discount. Start: 01/01/1995 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider

Important These reports are specifically about claims processed through Claim.MD. If you receive a payment reference with an Electronic Remittance Advice (ERA) for a claim handled by Claim.MD, it provides details about that particular payment. Importantly, Claim.MD reports don't deal with balancing your overall accounts receivable (A/R) . Instead, reports dealing with payments focus on the specific payment information related to individual claims processed through Claim.MD. All the reports listed below are found in the Reporting page which is located in the left navigation menu.  Billed Charges by Payer: Why Run this Report: Monitor revenue distribution: Gain insights into how your revenue is distributed among different payers. Identify high-paying payers: Discover which payers contribute the most to your revenue and focus on building stronger relationships with them. Detect underperforming payers: Identify payers with lower billed charges and explore opportunities to improve reimbursement rates

Basic API Workflow Please review the API Technical Documentation for guidance on configuring the Claim.MD API. Workflow Considerations Consult with someone in your company who handles billing to better understand the normal workflow for submitting claims, receiving ERA and checking patient eligibility. Familiarize yourself with the typical process of receiving both a claim status update from the payer and payment details as part of a payer EOB/Remittance. Understanding this workflow can enhance your integration and utilization of the provided services. The ‘Accept’ HTTP header controls if API results are returned in the XML (application/xml) or JSON (application/JSON) formats. You must determine if your users will have their own Claim.MD accounts with direct access to the portal, or if the software vendor will retain a single Claim.MD account and offer no Provider access. Provider Direct Access - Minimum Requirements If each provider/customer will have

Situational XML / JSON Field mod1, mod2, mod3, mod4 X12 Loop / Segment SV202-3 through SV202-6 (Modifiers) Allowed Values 2 characters Notes Field Name Service Date Description  "Dates of Service," is the date when services were first provided. Paper Claim Block 45 Required / Situational Required XML / JSON Field from_date X12 Loop / Segment Loop 2400 - DTP01 (Value 472 – Service date), DTP02 (Value D8 – Format:, CCYYMMDD or RD8 – Date Range)DTP03 (Date or Dates) Allowed Values Date yyyymmdd Notes Field Name Units (Service Units) Description This captures the quantity of healthcare services provided, such as "5" for inpatient days or "3" for outpatient visits, crucial for precise billing and claims processing. Paper Claim Block 46 Required / Situational Required XML / JSON Field units X12 Loop / Segment Loop 2400 - SV204 (Value DA – Days or UN –Units), SV205 (Service Unit Count) Allowed Values (dropdown UN/DA) and 6 characters for number of units

The Manage Users page in Claim.MD enables administrators to create, delete, and manage user access and permissions. This ensures that only authorized individuals can access sensitive information and perform critical tasks. Access to this page is restricted to administrators only. User Types Administrator: Has full control over user management, settings, and system features. Only administrators can configure SFTP/API setups. Standard: Access can be limited to specific features, but users can view all provider data within their permitted features. Eligibility Only: Restricted to eligibility access for a single provider, with no visibility into eligibility history. Accounting/Invoices: Limited to the View/Pay Invoices page. HIPAA Compliance To comply with HIPAA regulations, each user must have unique login credentials exclusive to Claim.MD. Sharing login information compromises the confidentiality of personal health information and is strictly prohibited. Adding a New User Click the Manage Users button on the left-hand

View/Pay Invoices The View/Pay Invoices page allows organizations to review their invoices, update their recurring payment method, and make one-time payments to Claim.MD. Click on the View/Pay Invoices page in the left-hand navigation panel. Current Account Balance The **Account Balance** pane at the top of the screen displays the current balance due. Invoice History The Invoice History section in the middle of the screen allows users to review past invoices. Click on any blue link (Date, Invoice #, New Charges, etc.) to view a detailed invoice for that billing period. Understanding Invoices Balance Forward: Displays any unpaid balance from previous invoices. Transaction Fees: For plans with per-transaction charges, the number of processed claims and ERAs and their associated fees are displayed. Subscription Fee: Monthly or annual fees are itemized. Tax ID Fees: For applicable plans, additional fees based on Tax IDs are included. View

This section helps verify a patient's insurance coverage, determine covered services, and identify any co-payments or deductibles the patient may owe. Steps to Check Eligibility      Navigate to Eligibility in the left navigation menu.      Select a Provider from the dropdown.      Choose a Payer from the second dropdown.      In the Eligibility Information dropdown, select:                       Benefit Type (selected from the dropdown), or              Procedure Code (entered manually).                    Provide patient details— Policy# or Date of Birth is required.      Click the          Check Eligibility button to generate results.           Important      Most payers do not respond to the Procedure Code and only recognize the Benefit Type. Eligibility Results      Use the Jump to Benefit Category dropdown to navigate directly to specific categories like Pharmacy, Urgent Care, and Physical Therapy.           Web Portal Request Limits      The portal has limits on eligibility checks per second. Exceeding the limit results in: "Error: Too many requests. Try again later." Prevent Unnecessary Eligibility Requests

claims by clicking the Approve Transmit button. d. A pop-up will confirm the number of claims marked for transmission (e.g., "51 claims are marked to transmit"). Click OK to clear the pop-up. Turning Off Transmit Approval Required If your organization wishes to transmit claims automatically without prior approval on the Manage Claims page, an administrative user can achieve this by navigating to the Settings page on the left navigation menu. Once there, they can click on the Account Settings tab and unselect the option for "Transmit Approval". The Account Settings article has more information about this and other settings.  Conclusion: Transmitting documents, such as medical claims, in Claim.MD is essential for seamless healthcare billing and reimbursement. SFTP and API are reliable methods to transfer data from your PMS or billing software to Claim.MD. Remember to monitor the "Pending Approval" notification and ensure that claims are

Start: 02/28/1997 320 Study models. Start: 01/01/1995 322 Recent Full Mouth X-rays Start: 01/01/1995 | Last Modified: 10/17/2010 323 Study models, x-rays, and/or narrative. Start: 01/01/1995 324 Recent x-ray of treatment area and/or narrative. Start: 01/01/1995 325 Recent fm x-rays and/or narrative. Start: 01/01/1995 326 Copy of transplant acquisition invoice. Start: 01/01/1995 327 Periodontal case type diagnosis and recent pocket depth chart with narrative. Start: 01/01/1995 329 Exercise notes. Start: 01/01/1995 330 Occupational notes. Start: 01/01/1995 331 History and physical. Start: 01/01/1995 | Last Modified: 08/01/2007 333 Patient release of information authorization. Start: 01/01/1995 334 Oxygen certification. Start: 01/01/1995 335 Durable medical equipment certification. Start: 01/01/1995 336 Chiropractic certification. Start: 01/01/1995

For Maine Medicaid, the "Service Location" ID (or Facility ID) in the Facility block 32 ( 2310C ) must be an alphanumeric value formatted as "xxxx-xxx" with a dash. Inquiries for Maine Medicaid For more details on Maine Medicaid 837P protocols, please refer to this companion guide . For more in-depth inquiries, please refer to the contact information here: MaineCare Contact .

Other Carrier Codes When sending secondary claims to South Carolina Healthy Connections Medicaid , or when passing an other payer ID, this payer requires their proprietary payer ID's (Carrier Code). Reference the South Carolina Medicaid Carrier Codes page for a list of allowed codes.  Secondary / Other payer ID's can be sent in block 9d for Professional Claims and block 51b for Institutional Claims. Facility Claim Institutional Claim Medicaid Provider ID and NPI Crosswalk Per HIPAA 5010 X12 standards, Medicaid is not allowed to receive a Medicaid provider ID on electronic claims, if the provider has an NPI. This payer uses a table of information or "crosswalk" to associate the payer assigned provider IDs to each claim. Verify the information sent in these fields matches the provider ID record in the payers system: Provider NPI Provider Address Provider taxonomy code

Note A maximum of 10,000 claims will be accepted in any one file, regardless of the file format. Any claim data sent beyond this quantity will not be processed. To submit more thank 10k claims, split the claim data into multiple files. ANSI X12 (837) Supported ANSI X12 file formats: 837P = Professional Claims 837I = Institutional Claims 837D = Dental Claims Companion Guide X12 Segment Definition Expected Value ISA01 Author Info Qual 00 ISA03 Security Info Qual 00 ISA05 Interchange Sender ID Qual ZZ ISA06 Interchange Sender ID [Claim.MD Acct #] ISA07 Interchange Receiver ID Qual ZZ ISA08 Interchange Receiver ID CLAIMMD GS02 Application Sends Code [Claim.MD Acct #] GS03 Application Recs Code CLAIMMD Single Line Claim File (XLS/CSV) Spreadsheet claim format, with all claim data and procedures on a single row. Format is CSV (Comma Separated Values) or XLS (Office Excel 97) Supported Column Definitions Professional Claims CSV Example