ERA Accuracy Rate

ERA Accuracy Rate

KPI Details

Electronic Remittance Advice (ERA) Accuracy Rate measures the percentage of initial ERA claims denial or adjustment messages sent to healthcare providers that contain accurate information regarding possible claims adjustments and/or denial reasons. ERA 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. 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. A high rate of inaccurate 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.).

KPI Definition

The total number of initial electronic remittance advice (ERA) claim denial or adjustment messages provided by the insurance company that include accurate adjustment messages and/or denial reasoning divided by the total number of ERA messages sent by the insurer to healthcare providers over the same period of time, as a percentage.

KPI Best Practices

• Maintain up-to-date systems regarding claims rules, edits and member data
• Standard or validated data inputs where necessary to minimize input errors
• Place high investment in customer satisfaction and customer experience

KPI Calculation Instructions ERA Accuracy Rate?

Two numbers are used to calculate this KPI: (1) the number of initial electronic remittance advice (ERA) messages sent to healthcare providers by the insurance company, and (2) the total number of initial ERA messages sent over the same period of time. Include only error-free ERA messages in the numerator for this calculation. Initial ERA messages should include only the first ERA message sent following initial claims adjudication (i.e., do not include ERA messages sent to correct errors in the initial message in this calculation - for both the numerator and the denominator).

KPI Formula :

(Number of Accurate Initial ERA Messages Sent / Total Number of Initial ERA Messages Sent) * 100