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Claims

A claim is a list of services which have been provided to a patient which is sent to an insurer for reimbursement.

The Claim Form is divided into multiple tabs for an organized view of the complete claim.

Claim Details

  • Claim Number - a unique identifier for the claim.
  • Claim Type - the category of claim (e.g. professional, institutional, oral, pharmacy, vision).
  • Place of Service - the location on the encounter.
  • Total Billed - the sum of the amounts billed for each claim line in the claim.
  • Diagnosis Codes

The Patient & Coverage Details section of a claim display information from the patient record and the patient's coverage.

  • Patient
  • Date of Birth
  • Patient Address
  • Gender
  • Member Id
  • Coverage
  • Payer

Rendering Provider Details

  • Rendering Provider - populated based on the claim settings for either the business unit, payer, or authorization.
  • NPI - NPI of the practitioner populated as the Rendering Provider.

Referring Provider Details

  • Referring Provider - the referring provider on the episode of care
  • NPI - NPI of the contact populated as the Referring Provider

The Paid Amount Details section displays on a claim when a remit was already posted to the claim.

  • Total Paid - Claim Submissions - the payment amount on the remit.
  • Total Paid - All Submissions - the sum of the payment amounts on any remits posted to any submissions of this claim.
  • Total Cost Share Paid - the sum of the payment amounts on any cost share remits posted to any submissions of this claim.

The Oustanding Amount Details section displays on a claim when a remit was already posted to the claim.

  • Total Expected - the expected amount based on quantity of units billed and the fee schedule for this service.
  • Total Paid - the sum of the payment amounts on any remits posted to any submissions of this claim.
  • Total Cost Share Adjustments - the sum of the adjusted amount on any cost share adjustments on any remit lines or remits on any submission of this claim.
  • Total Write-Offs - the sum of the write-off amount on any write-offs posted to any lines of this claim, on any submissions of this claim.
  • Total Outstanding - the difference between the Total Expected and the Total Paid. Write Offs and Cost Share Adjustments are deducted from this total so that it presents the balance due from the payer.
  • Total Cost Share Oustanding - the difference between the Total Cost Share Adjustments and the Total Cost Share Paid. This represents the cost share balance.

The Submission Details section displays on a claim when the claim has been modified and resubmitted.

  • Claim Frequency Code
  • Original Reference Number
  • Delay Reason Code

The Claim Lines subgrid displays the claim items on the claim. Read more about claim items.

The Additional Claim Info tab contains other information sometimes relevant to claims:

  • Billing Provider
  • NPI
  • Tax ID
  • Facility

The Submissions Summary tab shows a list of submissions representing the full story of the claim (how and when it was submitted, modified, resubmitted, etc.).

Claim Statuses​

  • Draft - Claim has not yet been submitted and fields can be edited.
  • Ready to Submit - Claim has been saved and submitted and can no longer be edited.
  • Submitted Submission - Claim has been submitted to the clearinghouse.
  • Historical Submission - Claim has since been modified and resubmitted, and this is a historical record of a previous submission.

There are 6 views configured for easy access to viewing claims based on their statuses:

  1. All Claims
  2. Draft Claims
  3. Historical Claims
  4. Ready to Submit Claims
  5. Submitted Claims
  6. Inactive Claims

Submit Claims​

To submit claims, click 'Save & Submit' on any draft claim. The claim status will become 'Ready to Submit'. All 'Ready to Submit' claims are submitted to the clearinghouse on an hourly basis.

Modify and Resubmit Claims​

To modify and resubmit a claim, click 'Modify & Resubmit' on any submitted claim. A new Draft Claim will be opened with all of the information from the previously submitted claim.

The previously submitted claim's status will be set to 'historical submission' and will be displayed on the submissions summary tab on future claims with that claim number.