Provider Enrollment

Payer EDI, ERA and EFT Enrollments:


Clearing House:

Clearing house are companies that function as intermediaries who forward claims information from healthcare providers to insurance payers as well as receive the electronic remittance advice from insurance payers to healthcare providers.

They transfer ANSI 5010 transaction and acts as a submitter (Claim Submission)/ receiver (ERA). Medical claims cannot be submitted to insurances without approval from Insurances/Payers. Each insurance has a Submitter ID and Receiver ID. Submitter and receiver id can be unique or different. For electronic claim submission ANSI 5010 needs to be setup based on payer requirements and it has about more loops which needs to be present for electronic claim submission.

It would be a tough job for medical provider to complete all these steps to submit claims to insurance companies. To ease up the submission process, Providers started using clearing houses for submission of claims.

EDI Enrollment: (Clearinghouse Authorization)

EDI enrollment is to let the payer know that you will be submitting claims electronically, and what clearinghouse your claims will be going through. Each Insurance/payer assigns submitter ID to the clearing house. Provider needs to link with the clearing house “Submitter ID” which is assigned by respective payer for submission of electronic claims.

Payers can be classified into two types based on EDI requirements;

  1. EDI Required Payer
  2. EDI Pre-Assigned Payer
EDI Required PayerEDI Pre-assigned Payer
Payers that requires compulsory EDI enrollment – like Medicare, RR Medicare, some states of Medicaid & BCBS etc…Payers does not need any paper work – Most of the commercial payers like Aetna, Cigna, Human, UHC etc..
Application can be Electronic or thru PaperNo application is needed.
Claims can be submitted directly through clearing house for respective payers after EDI approval from payer.Claims can be submitted directly through clearing house for respective payers.

ERA Enrollment: 

An Electronic Remittance Advice (ERA) is the electronic version of an Explanation of Benefits (EOB). These are also known as 835 remit files. ERA enrollment is necessary for receiving electronic EOBs through clearing house. Whichever payer has an ERA option can be enrolled for an ERA.

EFT Enrollment:

Electronic Funds Transfer (EFT) is a system of transferring money from Payer bank account directly to Provider/Practice bank account without any paper money changing hands. The main purpose of EFT enrollment is to avoid manual paper checks. EFT enrollment is done through online or paperwork based on payer requirement. Some insurances require EFT enrollment in order to receive ERA.

Benefits of EDI, ERA and EFT Enrollments:

EDI avoids manual claim forms to be sent to payer thereby decreasing the need for manpower, time and money.

EDI provides easy way to track claims and provides us with updated information on claim rejection and acceptance.

ERA is mainly to avoid paper/manual EOB.

ERA provides us with easy access to payment/denial information.

ERA reduces time spent on searching claims status and EOB.

ERA provides quick access to denial thereby enabling us to take appropriate denial action on time.

EFT is a secured payment method for the provider.

EFT reduces time and resource to deposit paper checks to the bank.

EDI, ERA and EFT is one-time work and once done it reduces Manpower, Time and Cost.