Working with Claims
Click on 'Claim Submission' under 'RCM Actions' to view and work on claims and its related details. For quick access, buttons like 'Patient Info', 'Billing Info' and 'Settings' are provided on the top right corner of the claim submission view.
Providers & CPT setup
Quick access button 'Billing Info' can be used to add various providers, procedure codes, service facilities, payers, outside labs and other items needed to generate claims.
The details of already available Rendering Providers, CPTs, Billing Providers and other items can be listed and edited by selecting the corresponding type in the type combo as shown below.
Patients, Procedure Codes, Billing Providers, Referring Providers, Ordering Providers, Outside Labs, Payer and Pay to Address are common and shared between EHR practice and RCM.
Generating and Editing Claim
Encounters that are ready for generating claims can be listed on searching 'Encounters for Claim Generation' in the type combo. Encounter summary, insurance details, and patient insurance eligibility can be viewed for that encounter using the action items.
Claims can be generated by clicking 'Generate Claim' action which takes through a simple four-step claim wizard as shown below. Data provided on the encounter in chart notes will be automatically get filled up in these wizards.
Claim Wizard 1 (Patient, Guarantor & Patient condition Information)
Claim Wizard 2 (Insurance Information)
Claim Wizard 3 (Patient Treatment Details)
Claim Wizard 4 (Facility and Provider Details)
The generated claim can be saved as 'Draft' or 'Verified'. A claim can also be generated without an encounter by clicking the 'Generate New Claim' button. Claims in 'Draft' or 'Verified' status are not included in any of the reports.
Generated claims can be viewed by searching 'Generated Claims' in the type combo. Various actions are provided against the claim as shown below.
- Change Claim Status - Status of a claim can be changed using this action.
- Claim History - Lists activities done on a claim by members. This can be used for audit.
- Notes / Remarks - Claim related comments or notes can be added.
- Generate / Preview Claim
- Generate PIF - PIF file of this claim will be generated for submission.
- Claim PDF for Print - A PDF file will be generated for printing in the CMS1500 form.
- Patient Details - Patient insurance details, Notes and Eligibility History can be viewed.
- Patient Details - Patient insurance details, Notes and Eligibility History can be viewed.
- Others
- Add Attachments - Files like EOB and any consent forms can be attached and viewed in this section.
- Tasks - Tasks related to this claim can be added and assigned to another RCM member.
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
A secondary claim can be generated using 'Generate Secondary Claim' under 'Others' in the claim action items. Claims will have the same information of the primary claim which can be modified in a four-step claim wizard. Secondary claim id will be generated with primary claim id appended with the letter 'S'.