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 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 How to Set up Automatic ERA Reconciliation

Automatic reconciliation of received Electronic Remittance Acceptance (ERA) payments is now available for organizations to use. The “Automatic ERA Reconciliation” section of the Claims module Settings contains configuration options for automation at the organization level where users can enable and configure their settings. Organizations that do not have the Auto ERA Reconciliation feature enabled will not see this settings screen. Please note, it is recommended that only organizations who have agreed rates enabled for billing settings should use this feature.

To set up the Automatic ERA Reconciliation screen, organizations need to:
  1. Navigate to the Claims module and select Settings
  2. Click Automatic ERA Reconciliation 
  3. Enable Automatically reconcile fully paid payments for agreed rates. Please note, agreed rates must be enabled for the organization. This will reconcile payments where total agreed charges are equal to the received insurance payment and patient responsibility.
    • Enter an optional label in the “Additional billing entry label(s)” search bar. This label will appear once the payment is reconciled to the associated billing entry for fully paid claims only. The list of available labels is pulling from the billing labels set for the organization.
  4. Enable Automatically reconcile partially and over paid payments. Please note, it is recommended to only use this feature if the organization has agreed rates enabled for billing purposes. This option will reconcile any payments received in the system regardless of amounts received.
    • Enter an optional label in the “Additional billing entry label(s)” search bar. This label will appear once the payment is reconciled to the associated billing entry for partially paid payments only.
      • Exception: If organizations utilize this feature without agreed rates turned on, but have opted into automation of partially and over paid payments, then all reconciled entries in the billing screen regardless of fully or partially paid payments will utilize the billing labels specified within the settings for partially paid payments. Please note, the list of available labels is pulling from the billing labels set for the organization.
  5. Optionally, enable Reconcile patient responsibility adjustments. Reconciled patient responsibility will be applied to the patient responsibility amount on billing entries that are posted through the automation process.
  6. Click Save Changes

The following exclusions apply at either the claim level of payment and service line payments in each claim:

  • Claim Adjustment: Claim has an adjustment that needs to be manually reviewed prior to reconciling any service line.
  • Mismatch Service: If the service code or service date does not match the billing entry, the claim cannot be reconciled.
  • Orphaned Claim: If the payment’s claim cannot be identified, the claim cannot be reconciled.
  • Orphaned Service: If the payment’s service line cannot be identified, the claim cannot be reconciled.
  • Voided Billing Entry: If the previous billing entry was voided and therefore, it cannot be identified or tied back to a certain client, it cannot be reconciled.
  • Agreed Rates Off: If the organization only wanted to process fully paid claims but they have agreed rates off.
  • Combined and Agreed Rates Off: If the organization is trying to process combined lines but they have agreed rates off.
  • Combined and Negative Payment: If the organization is trying to process combined lines but the payment is negative.

Claim Module Status Addition to ERA List 

Users can then navigate to the ERA List and view the “Auto Reconciled Status” column for a status on what has been processed. The following are statuses in the column:

  • Pending: The automation process is still in progress. Claims cannot be manually reconciled until the process is completed.
  • Completed: The claim has gone through the reconcile process and per setting configurations, was reconciled into the billing screen.
  • Not Applicable: The automation process is either disabled or was not enabled when the ERA was received.
  • Unprocessed: The ERA was queued for auto reconciliation, but the process never started or completed and the reconciliation lock on the ERA expired.

Please note, organizations that do not have the Auto ERA Reconciliation feature enabled will not see this new column.

Claim Module Status Addition to Claim Payment View

Users can then navigate to the specific ERA and view the “Auto Reconciled Status” column for a status on each paid service on each claim. The following are statuses in the column:

  • Completed: The automation process is completed and the payment was reconciled and posted payment entries on the billing screen.
  • Pending: The automation process is still in progress. Claims cannot be manually reconciled until the process is completed.
  • Not Applicable: The automation process is either disabled or was not enabled when the ERA was received.
  • Unprocessed: The ERA was queued for auto reconciliation, but the process was never started or completed, and the reconciliation lock on the ERA expired.
  • Exclusion Status:
    • Claim Adjustment: Claim has an adjustment that needs to be manually reviewed prior to reconciling any service line.
    • Mismatch Service: If the service code or service date does not match the billing entry, the claim cannot be reconciled.
    • Orphaned Claim: If the payments claim cannot be identified, it will be flagged as orphaned.
    • Orphaned Service: If the payments service line cannot be identified, it will be flagged as orphaned.
    • Voided Billing Entry: If the previous billing entry was voided, and therefore cannot be identified or tied back to a certain client, it cannot be reconciled.
    • Agreed Rates Off: If the organization only wanted to process fully paid claims but they have agreed rates off.
    • Combined and Agreed Rates Off: If the organization is trying to process combined lines but they have agreed rates off.
    • Combined and Negative Payment: If the organization is trying to process combined lines but the payment is negative.
  • Unbalanced Amount: Only fully paid claims are enabled for reconciliation. Anything that has not been reconciled as fully paid will be tagged with this status.

Only the first reason discovered will be tracked and displayed.

Click here to learn more about ERA filters.

Claims / Claims / ERA List How to Use the ERA Payments Screen Filters

When selecting a claim, the Filters panel on the left-hand side contains filters to view specific payments with an orphaned claim/service, types of insurance, claims IDs, payors, and reconciliation status. 

  1. Navigate to the Claims module and select ERA List 
  2. Filter the ERA list by date and select a claim 
  3. Click the funnel icon on the left-hand side to view the Claims filters 
  4. Apply the following filters: 
    • Claims: filter by claims or services. 
      • Orphaned Claims: filter by orphaned claims or services within an ERA. 
        • Select Yes to display orphaned claims and services. 
        • Select No to display claims that are not orphaned or do not contain orphaned service lines. 
      • Claim ID: search and select claim IDs. 
    • Clients: select clients from a drop-down or search and select multiple clients.
    • Reconciled: filters by claims that have already been reconciled. 
      • Select Yes to display reconciled claims. 
      • Select No to display claims that need review. 
      • The following selections are available in the Auto Reconciliation Status drop-down: 
        • Complete 
        • Combined Service 
        • Mismatch Service 
        • Orphaned Claim 
        • Orphaned Service 
        • Void Billing Entry 
        • Unbalanced Amount 
    • Payer: filters by clients’ primary or secondary insurance within an ERA. Search for specific payors, filter by Primary or Secondary options, or select a specific group code in the “Group” drop-down. The following are group options:  
      • CO: Contractual Obligations 
      • CR: Correction and Reversals 
      • OA: Other Adjustments 
      • PI: Payor Initiated Reductions 
      • PR: Patient Responsibility 

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.