Tips for Selecting a Software or Service Vendor

Choosing an electronic claims system means deciding between two basic options. You may either file claims directly with Pennsylvania Medical Assistance or submit them through a service bureau or clearinghouse.

Direct-filing systems usually cost more upfront. They are less expensive in the long run, however, because you don't have to pay the per-claim fees charged by the service bureaus or clearinghouses. For that reason, many smaller practices choose the direct-filing option. It may still be necessary to send paper claims to other insurers.

Typically, claims sent to service bureaus or clearinghouses are electronically edited for accuracy, format, and completeness. Then they are sorted and distributed to the appropriate carriers. Incorrect or incomplete claims are returned to you for correction and resubmission.

Regardless of how your claims are filed, you remain ultimately responsible for their accuracy and timeliness. It is your responsibility to provide billers with information received from the Department. Additionally, you should be aware that some electronic claims cannot be processed by Medical Assistance due to incorrect format or invalid provider information. These claims will not appear on your weekly remittance advice, but are returned electronically to the service bureau or clearinghouse. You should check with your selected service bureau or clearinghouse to confirm that they understand they are responsible for correcting and resubmitting these claims.

You may find the tips below helpful in choosing a vendor:

  • Ask your practice management consultant (if you have one) to recommend a qualified dealer or software system.
  • Ask your colleagues in similar practices about their experiences with electronic claims submission. Visit their offices to see the systems in operation. Ask them about the features they like and don't like. Ask about their satisfaction with the service received from the vendor.
  • Visit the vendor displays at the next professional meeting you attend. Discuss your specific needs with the salespeople. Read their literature, examine their systems, and ask for a demonstration.
  • Check out the vendor's credit record, business history and financial condition. Ask each vendor for a list of local clients in your field of practice.
  • Determine whether the vendor's system will integrate with your existing system. Ask if you'll get credit for the cost of a software upgrade after a few years.
  • Make sure that any new computer or software system you buy will be capable of electronic claims submission to Pennsylvania Medical Assistance.
  • Find out how often your vendor will update your system to comply with changes to Pennsylvania Medical Assistance. Will the vendor reprogram your system at no extra charge?
  • Ask about provisions for training your staff on the new software system. The level of support you receive after you buy the software is an important factor as well.

All Software Vendors and Clearinghouses/Service Bureaus must be certified by Gainwell to ensure their product is HIPAA/Promise™ compliant. It remains the responsibility of the provider to ensure that correct data is submitted in order for the Medical Assistance Program to successfully process transactions.

Questions regarding certification should be directed to Gainwell's Provider Assistance Center at 1-800-248-2152 (local 717-975-4100). Please note that neither the Department nor Gainwell can assist with recommending a Software product or Clearinghouse.