Claims

The Claims Module is presented by a plus sign icon, and is where claims for various insurance companies with exact preferences for each payer are set up. Through this module, the user can review timesheets and bulk merge claims for submission.

Claims Claims not Combining

Claims will not combine if line items have different service codes, dates, or locations. In an authorization, the “Use Service Location” toggle overrides the default address that is set up in Claim Settings. Therefore, claims will not combine if an address is not the same, or if a service code does not have an address set in the appointment details.

To turn the “Use Service Location” toggle on/off:

  1. In an authorization, navigate to the “Authorizations” tab
  2. Hover over each of the grouped service codes and click the pencil icon on the right-hand side.
  3. In the “General” tab, select the Use Service Location  toggle if all of the service codes in the authorization need it turned on.
    • Or, turn the toggle off if all of the service codes need the toggle off.
  4. Once the service location is the same for all codes, the claims will be combined when they are generated.

Click here to learn how to bulk merge claims.

Click here to learn how to manually combine service lines on a claim.

Click here to learn how to automatically combine service lines on a claim.

Claims Creating Secondary Claims

Once a primary claim has been generated, secondary claims can be generated whether an electronic payment or paper EOB has been received.

Prior to the 8.6 release, follow these steps to send a secondary claim:

  1. Navigate to the $ Billing module and select Billing
  2. Enter the name of the client to process a secondary claim for in Search billing entries
  3. Click the gear icon on the right-hand side of the billing entry under the “Options” column and select Claims Generated
  4. In the Claims iconClaims module, click Actions on the right-hand side, and select Generate Secondary Claim
  5. Click Generate in the “Confirm” pop-up
  6. In the claim, review and complete the information in each tab, including the “COB” tab
    • The “Policy Number” and “Group Name” fields in the COB tab correlate to 9a and 9d, respectively, on the CMS 1500 form.
  7. Click Save & Move to Inbox

The following steps featuring the “Adjudication” tab are coming soon.

To create a secondary claim with an ERA:

  1. Navigate to the Claims module and select Claims Manager
  2. Click Actions next to the claim and then Generate Secondary Claim
  3. In the claims editor, click COB and then the Adjudication tab, which displays the primary claim ID the secondary claim was generated from
  4. Review the fields in the “Adjudication” tab, which include but are not limited to:

    • “Service line adjudication and adjustments”, if different from the ERA received. 
      • Please note:
        • If multiple payments have been received, information based on the most recent non-negative payment will pre-populate
        • When editing “Charges” and “Amount paid”, all lines are now balanced in real-time to ensure the total charges are equal to the amount paid and adjustments. 
    • The “Policy Number” and “Group Name” fields in the “Payor” tab, which correlate to items 9a and 9d in CMS 1500 forms, respectively
    • The line entries for the services rendered. Change procedure codes or add additional information, if necessary
  5. If any changes need to be made, click Modify
    • Select a reason in the Reason for modification* drop-down
    • If “Other” is selected, enter the Reason*
    • Click Continue
    • Please note, by default, organizations’ COB Payment Settings are set to require modification reasons. Admins can edit these settings to either “Optional” or “Not needed”
    • Click Save & Move to Inbox
  6. To view any edits made to the “Adjudication” tab, click History and then Refresh
  7. To submit the secondary claim, navigate to the Claims module and select Claims Manager
  8. Click the Actions drop-down next to the claim and select Send to Gateway
    • Please refer to your state Medicaid office or payor for billing rules, such as combined claims
  9. To monitor claims in the clearinghouse or secondary payor portal, log into your secondary payor portal and manage transactions as necessary.

To create a secondary claim without an ERA:

  1. Navigate to the Claims module and select Claims Manager
  2. Click Actions next to the claim and then Generate Secondary Claim
  3. Click Continue in the “Generate secondary claim” pop-up to manually enter payment information
  4. In the claims editor, click COB and complete the fields in the Adjudication tab, which include but are not limited to:
    • Add the “Adjudication date”, “Total amount paid”, and any adjustments under “Claim level adjudication and adjustments”
      • When editing “Charges” and “Amount paid”, all lines are now balanced in real-time to ensure the total charges are equal to the amount paid and adjustments. 
    • Ensure the “Policy Number” and “Group Name” fields in the “Payor” tab correlate to items 9a and 9d in CMS 1500 forms, respectively. 
    • Enter first and last names correctly and ensure the “Policy/Group/FECA Number” matches the primary insurance ID.
    • The line entries for the services rendered. Change procedure codes or add additional information, if necessary
  5. Click Save & Move to Inbox
  6. To view any edits made to the “Adjudication” tab, click History and then Refresh
  7. To monitor claims, log into your secondary payor portal and manage transactions as necessary

Please note, changes will be saved and sent only with this claim. The original payment and billing entry will not be updated.

Click here to learn how to print a CMS-1500 form.

Claims How to Export a Claim as an 837 File

To export a claim as an 837 File:

  1. Navigate to the Claims module and select Claims Manager
  2. Select the claim(s) that need to be exported and click the Actions drop-down at the top of the grid
  3. Click Export/Download
  4. In the “Choose a download” drop-down, select a gateway. The gateway settings will use some fields in the export. 
    • If there are any claims errors, click the Ignore errors checkbox
  5. Click Export
  6. In the “Claims Export Progress” modal, select download next to the claim(s)
  7. Click Download in the “Download The File” pop-up

Claims How to Generate a TEST Claim

To generate a TEST claim:

  1. Navigate to the Claims module and select Claims Manager
  2. Check the box next to the claim
  3. Click Actions and select Export/Download from the drop-down menu
  4. Select a gateway
  5. Click Test claim
  6. Select Export

Claims Split Claims by Place of Service

To split claims by Place of Service:

  1. Navigate to the Billing module and select Billing
  2. Select the billing entries to be split
  3. Click the Actions drop-down and select Bulk Merge Claims
  4. Click the Split on Place of Service checkbox. The claim will split into one claim per client and per Place of Service
  5. Click Start claims generation once all changes have been finalized on the current, bulk-merge screen
  6. Once the claims have been processed, they can be submitted. To submit the claims, navigate to Go to claims inbox
  7. Select the claims to be submitted. Click the Actions drop-down and select Send to Gateway

Claims The MA-DPH Specification User Guide

DPH EI switched their claim process from a proprietary system to 837. This user guide contains the requirements for creating and downloading claims and reports required by the Massachusetts Department of Public Health Early Intervention (MA-DPH EI).

Claims Deleting a Claim and Invoicing a Payor

If you filed a claim, but want to invoice a payor instead, void that claim and generate an invoice.

To delete a claim and generate an invoice:

  1. Navigate to the  Claims module and select Claims Manager
  2. Select the claims entry you want to void and click  Trash Selected
  3. Generate the invoices, by navigating to the Billing module and selecting Billing
  4. Filter by the custom date range and client
  5. Check all of the entries you want to invoice for
  6. Click the Actions drop-down and select Bulk-generate Invoices
  7. Choose the invoice you want to generate

Click here to learn more about creating an invoice.

Claims / Tasks Create a New Task from the Claims Module

To keep track of action items and work pending to be completed, pertaining to claims, such as following up on a claim status to confirm it has been successfully processed by a defined due date, create tasks for claims from the  Claims module. Tasks created from the  Claims module include links to easily access the claims the tasks were created for.

To create a task from the  Claims module:

  1. Navigate to the  Claims module and select Claims Manager
  2. Click the checkbox  next to all claims you want to create a task for
  3. Click the Actions drop-down and select Add Tasks
  4. In the “Create task related to X claims” pop-up, complete the form with the following information:

    • Name: enter the name of the task
    • Description: optionally, enter a description of the task
      • Click Use a Template if creating a task using a task template
    • When is it due?: click on the calendar  icon to set a due date and time for the task
      • Assigning a due date will enable you to filter tasks in the tasks screen and in the  Tasks module’s main menu, by Due Today and Overdue
    • Who is responsible?: select one of the following from the drop-down:
      • You: if the task is assigned for you
      • Choose someone…: to assign the task to someone else
        • Find Person/Group: enter the name of the person, group, or label the task should be assigned to
      • Leave unassigned: if the task should not be assigned to anybody. Use this option to create a queue of tasks that can be worked on and completed by other users in the organization
        • Who can see this task?: select one of the following from the drop-down:
          • All co-workers in my organization: all users in the organization can view and work on the task
          • Only providers matching a label: only users with desired contact labels can view and work on the task
            • Select Contact Label: enter contact labels to apply to contacts who can view and work on the task
    • Is this task on behalf of a person?: select one of the following:
      • Yes: if the task is being created on behalf of another person
        • On behalf of: enter the name of the person the task is created for
      • No: if the task is not created on behalf of another person
    • Add Labels: enter labels to easily filter and organize tasks
    • Attachments: click Upload, Select Files, or drag the file to the Drop files here to upload to attach relevant documents to the task
  5. Click Create Task
  6. To access the task, click the number in the Tasks  column of the “Claims Manager” grid. This number indicates the numbers of tasks associated with the claim
    • Or, navigate to the  Tasks module and select All Tasks
      • Click the name of the task
      • When accessing the task, the list of claims the task was created for will be displayed on the bottom right-hand side of the task, with links to open and access each claim.