payers overview

Payers Overview

Payers Overview

Payers in ChartCaddy are categorized into four different types:
  1. Cash - There is only one cash payer and it is called SELF PAY. Claim items are generated for cash payers but not submitted electronically.
  2. Limited - Claim items are generated for limited payers but not submitted electronically. These payers are usually custom contracts with specific entities that are invoiced.
  3. OKHCA - Claim items are generated for OKHCA payers and submitted electronically directly to the Oklahoma Health Care Authority.
  4. Clearinghouse - Claim items are generated for clearinghouse payers and submitted electronically to whatever clearinghouse is configured for your organization. Currently AdminisTEP, Availity, and Office Ally are supported.

MCO Payers

There are three clearinghouse payers that are also contracted with the OKHCA to process claims for Oklahoma Medicaid clients. The three MCO payers require prior authorization for very few OPBH services. All three should have the same requirements for that, and one of them provides an online tool to look up services to see if prior authorization is required: https://www.aetnabetterhealth.com/oklahoma/providers/prior-authorization.html
  1. Aetna Better Health Oklahoma
    1. ChartCaddy Name: OK Aetna
    2. Support Website: https://www.echohealthinc.com
    3. Contact: Rita Hanson, hansonr@aetna.com
  2. Humana Healthy Horizons Oklahoma
    1. ChartCaddy Name: OK Humana
    2. Support Website: https://www.availity.com
    3. Contact: Kasi Hilley:  KHilley@humana.com
  3. Oklahoma Complete Health
    1. ChartCaddy Name: OK Complete
    2. Support Website: https://www.PaySpanHealth.com
    3. Contact: Yvonne Harnden, Yvonne.Harnden@OklahomaCompleteHealth.com

Availity Electronic Remittances

You need to jump through some hoops in order to get electronic remittances delivered to your Availity "SFTP Mailbox". This is super important because if that isn't happening then you have to spend copious amounts of your nonexistent free time manually reconciling claim items. This is the process you need to go through for each payer:
  1. On the main Availity homepage, go to "Claims and Payments" and under "EDI Clearinghouse" select "Transaction Enrollment"
  2. Click the blue "Enroll" button and select "Enroll a Provider"
  3. Enter your organization information and click "Continue"
  4. Select the payer you need ERAs from and then check the "Electronic Remittance Advice" checkbox.
  5. Select how you want remittance data aggregated (we used TIN) and check the box to agree to terms and conditions and click "Submit Enrollment"
  6. Click "Download Enrollment Instructions" and follow the instructions on the document.
The instructions in the last step are different for each payer. For Oklahoma Complete Health, you can do everything through the PayspanHealth.com website, but you then have to go back to Availity and manually update the Transaction Enrollment to let Availity know that you've completed the necessary steps through Payspan. For Aetna Better Health Oklahoma, you have to open a ticket through EchoHealthInc.com, complete and send a document to them, and then also upload the document through Availity. Once you get all the payers set up then all your claims submitted through Availity should (eventually) start to be automatically reconciled. To verify whether or not you have jumped through all the hoops correctly you can view the files in your SFTP mailbox on Availity and look for files that start with "ERA" for each payer.