Working with Claims

• Before you Begin Claim Generation
  1. Practices Using CharmHealth EHR
  2. Practices Not Using CharmHealth EHR
• Claim Generation Settings
  1. Claim Generation Settings for e-Claim
  2. Payer-Specific Claim Generation Settings
• Claim Generation
  1. Practices Using CharmHealth EHR
     1. Generating Claim
     2. Bulk Claim Generation
  2. Practices Not Using CharmHealth EHR
     1. Generating Claim
     2. Copy Claim
     3. Bulk Claim Import
        1. Import Claims in HL7 Format
        2. Import Claims in CSV Format
• Preview Claims
• Edit Claim
• AI-Powered Claim Validation Suggestions
• Claim Submission
• Transaction Status
• Secondary Claim Generation
• Claim Denials

Before you Begin Claim Generation

Before generating Claims in Charm BillerPro, ensure that all required billing information is available and correctly configured. The setup steps vary based on whether your Practice uses CharmHealth EHR or external EHR systems.

Practices Using CharmHealth EHR

For Practices integrated with CharmHealth EHR, most claim-related data are automatically shared and synchronized.

The following details are fetched directly from CharmHealth EHR and added automatically to the Charm BillerPro.

• Procedure Codes (CPT/HCPCS)
• Payers
• Patients
• Rendering Provider

  All Facility Members in CharmHealth EHR with a valid NPI and with a Physician role are automatically added as Rendering Providers in Charm BillerPro.

  To add a member from EHR who does not have a valid NPI and is not assigned the Physician role as a Rendering Provider in Charm BillerPro:

  1. Go to Claim Submission View > Facility Members in EHR.
  2. Select the required member.
  3. Click Add as Rendering Provider.
  4. Enter the required provider details and click Save.
  
  
• Service Facility

  The list of Facilities added in CharmHealth EHR will be available as Service Facilities in Charm BillerPro.

• Billing Provider
• Pay-to Address
• Referring Provider
• Ordering Provider
• Outside Labs

To review and verify these details:

1. Navigate to RCM Dashboard > RCM Actions > Claim Submission.
2. Select the appropriate option from the Claim Submission View dropdown.
3. Review the data before proceeding with Claim generation.
   

The details, such as Patients, Procedure Codes, Billing Providers, Referring Providers, Ordering Providers, Outside Labs, Payers, and Pay-to-Address are shared between the EHR Practice and RCM.

To add or modify these details, it is suggested to update them directly in your CharmHealth EHR account.

Practices Not Using CharmHealth EHR

Practices that are not integrated with CharmHealth EHR must manually add and manage all required billing data in Charm BillerPro before generating claims.

As a pre-requisite for Claim Generation, the Practice needs to add the following details under 'RCM Dashboard > RCM Actions > Claim Submission'.

1. Rendering Provider
2. Service Facility
3. Billing Provider
4. Ordering Provider
5. Referring Provider
6. Outside Lab
7. Pay-to Address
8. CPT Codes
9. Payer
10. Patients

To edit the above details, under the 'Claim Submission View' dropdown, select the appropriate options and update the changes.

Practices have the option to import the Payer list and Patient list.

Once all required details are configured and verified, you can proceed with the Claim Generation process.

Claim Generation Settings

To configure Claim Generation settings, navigate to 'RCM Actions > Settings > Claim Generation Settings'. These settings are applicable only for Practices using CharmHealth EHR during Primary Claim Generation.

Practices can configure how Claims are generated, either manually or automatically, with customized default values that make the process faster and more consistent.

Configure the options below to set the default values while generating Claims.

a. Auto Claim Generation Settings

Practices can automate the Claim generation process based on the configured Claim Generation Settings, reducing manual effort.

When enabled, Claims are generated automatically as soon as Invoices or Encounters are submitted to RCM from CharmHealth EHR.

Practices can then review, verify, and submit these Claims with ease under the 'RCM Actions > Claim Submission > Generated Claims' section.

To enable automatic Claim generation, follow the steps below.

1. Navigate to 'RCM Actions > Settings > Claim Generation Settings'.
2. Set 'Yes' for 'Enabled Automatic Claim Generation'.
   
3. Choose the Claim Status to be applied after auto-claim generation from the options below.
   1. Mark Claims as Verified, which has No Errors/Warnings/AI Suggestions
      • Clean Claims (without warnings or errors) are marked as 'Verified'.
      • Claims with validation errors or warnings are marked as 'Draft'.
      • It reduces review time for error-free Claims.
      • Ensures problematic Claims need attention before submission.
   2. Verified
      • All auto-generated Claims are marked as 'Verified', regardless of validation results.
      • Fastest processing for high-confidence Practices
   3. Draft
      • All auto-generated Claims are saved as 'Draft'.
      • Recommended for Practices that require manual review before validation.

b. Claim Primary Insurance Selection (Box #1a)

Choose your preference for the Primary Insurance selection in the generated Claim from the following: Patient's Active Primary Insurance, Patient's Any Active Insurance, or Insurance in Invoice.

Based on your selection, Payer-defined rules are applied during Claim generation. If no rules are configured for the selected Payer, the default settings for Claim generation are used.

c. Claim Secondary Insurance Selection (Box #9)

Choose the Insurance to be selected as the Secondary Insurance in the Claim. By default, the Patient's Secondary Insurance will be selected. If you choose 'Select', no Secondary Insurance will be associated with the Claim.

d. Rendering Provider (Box #31 & #24J)

• Choose the Provider to be populated as the Rendering Provider in Box #31. You can either set a priority ( e.g., Co-signed Provider > Signed Provider > Encounter Provider > Provider in Invoice) or select a default Provider.
• If two different Providers sign the Encounter, enabling this option will automatically populate one Provider in Box #31 and the other in Box #24J.

  For example,

  1. If the Chart has a Co-signer and Signed Provider, the Co-signer will be selected in Box #31 and the Signed Provider in Box #24J.
  2. If the Chart is Filed for Review, the Signed Provider will be selected in Box #31 and Encounter Provider in Box #24J.
• Configure the default Other Identifier for Rendering Provider to be selected automatically in Box #31 (e.g., State License Number) if required by the Payer. If no option is selected, the first available qualifier of the Provider will be selected for Box#31.
  

e. Service Facility (Box #32)

• Set the default Service Facility to be selected for Box #32. You can select either the Facility of the Encounter or choose any particular Facility.
• Select the default Other Identifier for Service Facility to be selected in Box #32.
  

f. Billing Provider (Box #33)

• Select the default Other Identifier for Billing Provider (Box #33). This additional identifier will be populated automatically alongside the primary National Provider Identifier (NPI) for the Billing Provider
• This option allows the Practices to select either the default Billing Provider for all Claims generated across the Practice or configure a unique Provider for each Facility.
  

g. Box #17 Preference

Define the priority for populating Box #17 by selecting either the Referring Provider, Supervising Provider, or Ordering Provider.

1. Referring Provider Box #17

   If the preference for Box #17 is selected as Referring Provider, you can choose from the three options below.

   • Patient's Referring Provider - Selecting this option will populate the Patient's Referring Provider in Box #17.
   • Default Referring Provider - Choose any specific Provider to be populated by default.
   • Do not choose any Referring Provider - You may choose to exclude the Referring Provider when generating Claims.
     
2. Supervising Provider

   You can choose to populate the Supervising Provider in Box #17 automatically only if it is different from the Rendering Provider (Box #31), or do not select any Supervising Provider.
   

3. Ordering Provider

   If the preference for Box#17 is selected as Ordering Provider, you can either set the default Ordering Provider to be populated automatically or opt not to choose any Ordering Provider.
   

Claim Generation Settings for e-Claim

Practices can decide how the Electronic Claims are transmitted to the Payers.

These settings focus on generating Electronic Claims for efficient submission and faster processing.

a. Send the Service Facility detail even if it matches the Billing Provider

• As per the ANSI 5010 specification for Electronic Claim Submission, if the Billing Provider and Service Facility Identifiers are the same, then the Service Facility details should not be sent as part of the Claim.
• By default, CharmHealth will not send Service Facility details in the Claim if it is the same as the Billing Provider.
• However, a few Payers require Service Facility details for processing the Claims, even if it is the same as the Billing Provider.
• In such cases, the user should select this option to send the Service Facility details in the Claim.

b. Send Rendering Provider detail even if it matches with Billing Provider

• As per the ANSI 5010 specification for Electronic Claim Submission, if the Billing Provider and Rendering Provider Identifiers are the same, then the Rendering Provider details should not be sent as part of the Claim.
• By default, CharmHealth will not send Rendering Provider details in the Claim if it is the same as the Billing Provider.
• However, a few Payers require the Rendering Provider details for processing the Claim, even if they are the same as the Billing Provider.
• In such cases, the user should select this option to send the Rendering Provider details in the Claim.

c. Send Other Identifier (Eg: Taxonomy Code, State License Number) even if the Facility/Provider has NPI

• As per the ANSI 5010 specification for Electronic Claim Submission, if a Facility or a Provider (i.e, Billing Provider/Rendering Provider/Referring Provider/Supervising Provider/Ordering Provider) has an NPI, then any other identifier (Eg: State License Number) of that Facility/Provider should not be sent as a part of the Claim.
• By default, CharmHealth will not send additional identifiers if NPI is available for that Facility/Provider.
• However, a few Payers require additional identifiers for Claim processing even if the NPI is available.
• For such Payers, the user should select this option to send an additional identifier in the Claim.
• The Electronic Claim form allows any of the five qualifiers in the Claim, namely:
  1. State License Number [0B],
  2. Provider UPIN Number [1G],
  3. Provider Commercial Number [G2],
  4. Location Number [LU]
  5. Taxonomy Code [ZZ].

d. Pay-to Address

Set a default 'Pay-to Address' for all Facilities or select a unique address for each Facility.

e. E-claim Submitter Type

Choose an individual consulting Provider or the Claim Facility as the default Submitter. By default, an individual Provider will be selected.

Payer-Specific Claim Generation Settings

Practices can tailor Claim generation settings for specific Payers. These settings streamline the automatic Claim generation process, minimize manual intervention, and facilitate faster Claim processing.

• By default, the system uses the general 'Claim Generation Settings' for both manual and automatic Claim generation. However, when you create Payer-specific configurations, these settings override the general settings for the selected Payer during Claim generation.
• Practices can create multiple Payer-specific configurations and choose values or options to address the specific Payer requirements.
• Payer-specific settings can be associated with multiple Payers, allowing users to choose either the Payer Name, Payer ID, or a combination of both.

During Claim generation, if the Payer selected in the Claim matches the Payer configured, these settings will be applied automatically.

To configure the Payer-Specific Claim Generation settings, follow the steps below.

1. Navigate to the 'Payer Specific Settings for Claim Generation' section.
2. Click the '+ Add Payer Rules' option.
3. Search and select the relevant Payers to configure the settings.
4. Enable the checkbox for appropriate settings and select the required option for each setting to meet the Payer's requirements.
5. To add more Payer configurations, click the '+ Add Payer Rules' option.
6. Click the 'Update' button to save the settings.

Claim Generation

Practices Using CharmHealth EHR

All Encounters submitted from CharmHealth EHR to RCM get listed under the 'RCM Actions > Claim Submission > View > Encounters for Claim Generation' section.

The Encounter Summary, Patient Details, Insurance Details, and Patient Eligibility History can be viewed from the 'More Options' (...) icon against the Encounter.

Generating Claim

The Claim generation process can be initiated for an Encounter with a single click by following the steps below. The configured Claim Generation Settings are automatically applied during the process.

1. In the 'Encounters for Claim Generation' view, click the 'More Options' (...) icon against the Encounter.
2. Select the 'Generate Claim(CMS 1500)' option. On clicking, Claim details from the Encounter will be automatically populated in the CMS 1500 Claim Form, and the Preview of the Claim will be shown.
   
3. The Warnings, Errors, Transaction Status, Patient Notes, Claim History, etc., get listed in the right pane. Edit the Claim by clicking the 'Edit' icon and update the necessary details if needed.

   Preview Claim
   

   Edit Claim
   

4. Click on the 'Save as Verified' button. The Claim status gets changed from 'Draft' to 'Verified'.

Bulk Claim Generation

1. To generate multiple Claims at once, select the Encounters and click the 'Generate Claim(s)' option under the 'Actions' button.
   
2. Select the following options to use in Claims.
   1. Place of Service - Choose to retain the Place of Service in Claims or change to a specified Place of Service.
   2. Modifiers - Choose to retain Modifiers in Claims or change to a specified Modifier.
   
   
3. Click the 'Proceed for Claim Generation' button to generate Claims for selected Encounters.
   
4. Once Claims are generated based on the configured settings, a Preview of the Claims will be displayed. If there are any warnings/errors, they are indicated by a warning sign beside the Claim. You can navigate to the Claims and edit as required.
5. On verifying the Claims, you can mark them as Verified.

Practices Not Using CharmHealth EHR

For Practices that use other EHR services, CharmHealth BillerPro enables them to generate the Claims from the 'Generated Claims' view.

Generating Claim

A Claim can be generated directly in Charm BillerPro by following the steps given below.

1. Navigate to the 'RCM Actions > Claim Submissions > Generated Claims View' section.
2. Click on the 'Generate Claim (CMS 1500 Form)' button.
3. Search and select the Patient's name. The Patient's details get auto-populated in the Claim Form.
4. Select the necessary details such as CPT, Providers, etc.
5. Verify the details and click on the 'Save as Draft' button.
   
6. Upon saving the Claim form, the Mandatory Missing Items, Warning, Errors, and Rule Violations of the Claim (if any) will be shown in the right pane.
7. Update the necessary changes and click on the 'Save as Verified' button.
8. The Preview of the Claim will be displayed after successfully generating it.

Copy Claim

Practices that do not use CharmHealth EHR have an option to copy the Patients' previous Claims when generating new Claims.

To populate details from the previous Claim of the Patient, follow the steps below.

1. Navigate to the 'Generated Claims' view and click on the 'Generate Claim (CMS 1500 Form)' button.
2. Search and select the Patient's name.
3. Under the 'Copy From Earlier Claims' dropdown in Box #2, choose the Claim to copy the details. You can view the details of the previous Claim by clicking the 'Claim Details' link.
   

Note: Encounter Date, DOS [24A], and Signature Date will not be copied from the previous Claim.

Bulk Claim Import

Practices can generate multiple Claims at once by importing Claim data in HL7 or CSV format. This option is useful for Practices importing visit data from external systems.

Import Claims in HL7 Format

HL7 import allows you to generate Claims using DFT_P03 message files exported from the EHR system.

To import the visit details in HL7 format, follow the steps below.

1. Go to the Generated Claims view.
2. Click the 'Import Claim Data – DFT_P03' button.
   
3. In the dialog box, review the instructions.
4. Select the HL7 file and click Import.

The system processes multiple DFT_P03 messages from the selected file and generates Claims accordingly.

Claim Generation Rules - HL7

To view or update the HL7 configuration rules, click on the 'Settings' icon in the Import Claim Data – DFT_P03 dialog box.

These rules define how data is created or updated during import.

• A default Billing Provider must be configured. All imported Claims use this Provider.
• If a Patient does not exist, a new Patient record is created.
• Patient demographic details are updated from the HL7 file if the update option is enabled.
• Insurance and Payer details are added or updated based on the HL7 data.
• New Providers (Consulting or Rendering) are added if they do not already exist, based on Provider Name and NPI.
• If update options are disabled, the imported data is used only for Claim generation and does not update existing records.

Note: All generated Claims will be in the 'Draft' status.

Import Claims in CSV Format

The 'Import Claims Data - csv' option under the 'Import Claim Data - DFT_P03' dropdown button is used to generate Claims for the visit details from the selected 'csv' file.

• A Claim gets created for each visit that has complete and accurate information.
• The details of each visit should be recorded as a separate row in the file in the format below.
  1. Patient First Name, Patient Last Name, Patient DOB, Patient Gender, Member ID, Facility Name, Facility Code, Date of Service, Provider Name, Provider NPI, Dx Primary, Dx Others, CPT 1, CPT 1 Rate, CPT 1 Unit, CPT 1 Dx Pointer, Billing Provider Name, and Billing Provider NPI.
  2. Mandatory fields: Patient First Name, Patient Last Name, Patient DOB, Patient Gender, Member ID, Date of Service, Dx Primary, and CPT 1.
  3. Either one of the following pairs should be available: Facility Name and Facility Code, Facility Name and Facility Code, Billing Provider Name and Billing Provider NPI.
  4. One row/visit should not exceed more than 10 CPTs, so <number> should be 1 to 10. If an optional field does not have any value, it should be represented with an empty value.
• After import, a summary report displays successful and failed records.
• The failed visits can be downloaded, corrected, and re-imported. A sample error file with the 'Reason for failure' is shown below.
  
• The successfully generated Claims are available in the 'Generated Claims' view with the 'Draft' status.

Pre-Requisites for Bulk Import

Ensure the following data are already available in the system:

• Patient with Insurance details
• Facility (Name and Code preferred)
• Billing Provider (NPI preferred)
• Rendering Provider (NPI preferred)
• Procedure Codes (CPT)

Follow the data format for the fields as shown below.

On importing the Claims, the Preview will be displayed automatically.

Preview Claims

1. A preview of the Claim appears whenever a Claim gets generated. You can also double-click on the details of the generated Claim to preview a Claim.
2. To preview multiple Claims at once, select the Claims and click the 'Preview' option under the 'Actions' button, and preview all Claims one by one.
   
3. All actions performed on a Claim are recorded in the Claim History. It includes activities such as Status change, adding notes, adding/updating payment details, adjustment, write-offs, Patient responsibility, etc. Each time a Claim is edited, a new version is created.
4. All Claim Warnings and Errors, Patient Notes, Attachments, Related Messages, etc., are shown in the right pane.
   

Edit Claim

A Claim can be edited to change any coding errors or warnings, correct the missing information, etc. To edit a Claim, follow the steps given below.

1. Navigate to the 'Generated Claims' view.
2. Click on the 'More Options' (...) icon against the Claim and select the 'Edit Claim (CMS1500 Form)' option.
   
3. Make the required changes and click on the 'Save' or 'Save - Ready for Resubmission' button.
   

To edit multiple Claims, select the claims and click on the 'Edit Claims' option under the 'Actions' button.

You can use the right arrow icon, as shown in the screenshot below, to navigate to each claim and make updates. Then, click either the 'Save' or 'Save - Ready for Resubmission' button.

AI-Powered Claim Validation Suggestions

The AI-Powered Claim Validation Suggestions provide intelligent, real-time guidance during Claim generation and editing.
This feature helps billing teams proactively identify issues, improve Claim accuracy, and significantly reduce Payer denials before submission.

These suggestions can be viewed in both the Preview and Edit Claim views.

Key Benefits

• Reduces Claim rejections and denials before submission
• Improves first-pass acceptance rates
• Saves time for the billing team by providing real-time support
• Ensures compliance with Payer-specific and CMS guidelines
• Provides clear, actionable feedback without disrupting the workflow

Intelligent Claim Analysis

Charm BillerPro performs a comprehensive analysis of the entire Claim, including:

• Procedure Code Validity
• Age Appropriateness Validation
• Gender Appropriateness Validation
• Modifiers Usage Validation
• Diagnosis and Procedure Compatibility
• Bundling and Unbundling
• Place of Service (POS) Consistency

This holistic evaluation ensures validations are context-aware and Payer-aligned.

Based on the analysis, the system automatically generates actionable suggestions across key validation areas.

This includes the following:

• Procedure Code Validity
  Detects invalid, inactive, or mismatched CPT/HCPCS codes.
• Diagnosis & Procedure Compatibility
  Ensures CPTs are clinically supported by the associated diagnosis codes.
  
• Gender Appropriateness Validation
  Identifies services that conflict with the Patient's gender.
• Modifiers Usage Validation
  Validates correct usage, necessity, and compatibility of modifiers (e.g., 25, 59, TC/26).
• Age Appropriateness Validation
  Flags procedures or diagnoses that are not suitable for the Patient's age.
  
• Bundling & Unbundling Checks
  Detects incorrect unbundling or missing bundled components based on Payer rules.
• Place of Service (POS) Consistency
  Verifies alignment between POS, procedure codes, modifiers, and Provider/Facility type.

Automatic and Continuous Suggestions

• Suggestions are generated automatically during Claim creation—no manual trigger required.
• When a Claim is edited, the AI engine re-runs validations in real time and updates suggestions instantly based on the latest Claim details.
  
• Resolved issues are automatically removed, ensuring users see only relevant and current suggestions.

Claim Submission

PIF files can be exported in bulk by clicking on 'Batch Claim PIF' which lists the claims in 'Verified' or 'Ready for Resubmission' state. One or more claims can be selected and downloaded as a PIF file. Claim status can be updated to 'Submitted' on generating Batch Claim PIF.

Transaction Status

Transaction status can be used to track the status of a claim until it reaches the payer. This can be viewed by clicking 'Transaction Details' in the claim action items. The transaction details view lists the claim's transaction history. New transaction status can be added using the 'Add New Transaction' link on the top right corner of the dialog as shown below.

Member with privileges can change the transaction status which can be managed in Admin Settings → Member List → Member Privileges.

Claims marked with transaction status 'Rejected by Payer' are pulled in the Reports → Denial / Rejection → Rejection Report.

Secondary Claim Generation

Practices can use the 'Eligible for Secondary Claim Generation' view to generate the Secondary Claims for Patients with active Secondary Insurance.

Click on the 'More Options' (...) icon against the Primary Claim, then select 'Generate Secondary Claim' from the menu.

While generating, the Secondary Claims will have the same information as the Primary Claim and can be modified in the Edit Claim View. The system automatically populates the Primary Claim adjudication details from both ERA and EOB (Explanation of Benefits) payments.

The Secondary Claim ID will be generated by appending the letter 'S' to the Primary Claim ID.

EOB Payment Details

Primary Claim EOB Details during Secondary Claim generation

Claim Denials

The Claim Denials feature offers a centralized workspace to monitor, track, and manage all denied Claims.

It provides clear insights into denial patterns, enabling Practices to:

• Identify recurring denial trends.
• Take timely corrective actions.
• Reduce repeat denials and improve reimbursement efficiency.

To access this feature, navigate to 'RCM Actions > Claim Denials'.

Practices can filter the Claims by:

• Claim Denied Date
• Claim Updated Date
• Encounter Date
• Claim Submission Date

a. Denial Watchlist

The Denial Watchlist provides a quick summary of denial activity, including:

• Total number of denied Claims
• Total denied amount
• Number of denied and resubmitted Claims
• Number of denied but not resubmitted Claims
• Number of partially denied Claims
• Number of fully denied Claims

Click on any widget to access a detailed Claim list view of the corresponding denial activity.

b. Automatic Grouping of Denials by Denial Category

All denied Claims are now automatically grouped by Denial Category, making analysis easier and intuitive.

For each Denial Category, Practices can view:

• Total Number of denied Claims
• Number of resubmitted and not resubmitted Claims
• Number of denied CPTs
• Total denied amount
• Average number of CPTs denied in the Category

Selecting a category automatically applies the Denial Categories filter and displays the related Claim details for that specific denial category, as shown in the screenshot below.

Click on the 'View' option next to a category to display the list of Claims denied under that category. You can review, edit, and manage these Claims as needed from the Claims List View.

c. Denied Claims List

In this section, Practices can view a complete list of denied CPTs with descriptions and denial reason codes.

The Denied Claims section displays all denied Claims along with their associated denial details, including:

• Invoice ID and Encounter details
• Denial date and Claim status
• Payer details
• Number of denied CPTs
• CPT-level denial codes and comments

Click 'Edit' to view the Claim and make required corrections or resubmissions.

d. View Denials Within the Claim

Practices can now view specific Claim Denials in the right pane, including the reasons and codes for these denials.