* Is High or Low Best: Higher is Better
ERA Transparency Rate measures the overall quality of Electronic Remittance Advice (ERA) messages sent by insurance companies to healthcare providers. ERA claims adjustment or denial messages typically include information related to the adjudication of a medical claim, including reasons why the claim might have been denied (e.g., missing information, patient not eligible for services, etc.) and how to potentially correct that issue(s) to garner an approval from the insurance company. A high rate of unclear or unactionable ERA messages may create additional work for the healthcare provider and the claims processing function of the insurance payer. Low quality ERA messages can greatly diminish customer service levels, lead to rework and reduced capacity within the claims function (and for administrative functions within healthcare providers), and may lead to costly disputes with healthcare providers (e.g., doctors, hospitals, etc.).
The total number of electronic remittance advice (ERA) claim denial or adjustment messages provided by the insurance company that include clear, actionable items and explanations divided by the total number of ERA messages sent by the insurer to healthcare providers over the same period of time, as a percentage.
Two numbers are used to calculate this KPI: (1) the number of electronic remittance advice (ERA) messages sent to healthcare providers that are considered to contain clear, accurate and complete information regarding the adjudication of the claim, and (2) the total number of ERA messages sent to healthcare providers over the same period of time. Healthcare providers (specifically, claims processing employees working for healthcare providers or healthcare systems) should be responsible for assessing whether or not the ERA message is clear enough to determine the action(s) required to complete claims adjudication. Count each ERA message sent to healthcare providers only once in the denominator and numerator for this calculation, even if the ERA message contains more than one remark code, or message.
(Number of ERA Denial or Adjustment Messages Including Clear Reasons and Action Items / Total Number of ERA Denial or Adjustment Messages Sent) * 100
The number of instances where the patient eligibility information initially returned by the health insurance company matched the final outcome of claim adjudication divided by the total numb...
KPI Type : Quality
Formula : (Number of Accurate Patient Eligibility Transactions / Total Number of Medical Claims Adjudicated) * 100
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