For a while now we've been having an issue with preauthorizations being sent by e-claims. Alot of them have gone missing somewhere between the clearing house and the payer. Anyway, I had the technical support at the clearing house look into it and they come back to me with this answer, that it is a certain 'flag' that is passed into the claim (the X12) by Open Dental that is causing the clearing house servers to reject it as invalid. The representative from the clearing house was suggesting that this is a 'bug' in Open Dental.
In the subscriber info there is a line that looks like this "SBR*P*18*184000***6***CI~" .
I was told the 'P' refers to the fact that this is a primary insurance. So, a preauth like this passes just fine.
Then, we have a good number of these preauths with a 'S' (meaning secondary) or 'T' (i.e. Tertiary?) even in some cases when the patient only has one insurance. These are all being rejected by the clearing house as invalid. They said that if the flag is not a 'P' then the primary insurance information should be in there and it isn't which is why it is being rejected.
So, question 1) Would it be possible for a preauth to be marked 'S' or 'T' even if it is a primary and only insurance? I have found two such examples and I was told by the clearing house rep that there are more.
Question 2) According to the X12 format, If the preauth is for a secondary insurance, should the primary insurance info be included? and is it included by Open Dental by default or do I have to explicitly set the secondary insurance in the claim edit window?
Thanks for your help.
e-claim preauthorization are missing info
-
jordansparks
- Site Admin
- Posts: 5770
- Joined: Sun Jun 17, 2007 3:59 pm
- Location: Salem, Oregon
- Contact:
Re: e-claim preauthorization are missing info
1. After reviewing the code closely, it looks like there's a bug that causes it to always send T for Tertiary. I added that to the bug list and it will be fixed shortly. So I'm not sure where the P is coming from in your successful preauths. What version are you using?
2. For a secondary preauth, yes you do have to explicitly set the "other coverage" for the claim to show the primary info.
2. For a secondary preauth, yes you do have to explicitly set the "other coverage" for the claim to show the primary info.
Jordan Sparks, DMD
http://www.opendental.com
http://www.opendental.com
-
jordansparks
- Site Admin
- Posts: 5770
- Joined: Sun Jun 17, 2007 3:59 pm
- Location: Salem, Oregon
- Contact:
Re: e-claim preauthorization are missing info
The bug I mentioned has been fixed.
Jordan Sparks, DMD
http://www.opendental.com
http://www.opendental.com
Re: e-claim preauthorization are missing info
I'm using 7.2.46, and I went back to look at the examples I had, and you are right, they are all marked 'T". Thanks for the bug fix.
The ones that have been passing through are apparently resulting from sending a claim and a preauth for the same person in the same batch, so I believe the resulting X12 file combines the subscriber/patient info for both those into one header with a 'P'. I am trying to locate the one with an 'S' but I think it is most likely a similar situation to the 'P' in which the insurance is a secondary rather than primary.
The ones that have been passing through are apparently resulting from sending a claim and a preauth for the same person in the same batch, so I believe the resulting X12 file combines the subscriber/patient info for both those into one header with a 'P'. I am trying to locate the one with an 'S' but I think it is most likely a similar situation to the 'P' in which the insurance is a secondary rather than primary.