7 Creating Claims

Learning Outcomes When you finish this chapter, you will be able to: 7-2 When you finish this chapter, you will be able to: 7.1 Describe the role of claims in the billing process. 7.2 Discuss the information contained in the Claim Management dialog box. 7.3 Demonstrate how to create claims in Medisoft. 7.4 Describe how to locate a claim that has already been submitted. 7.5 Discuss how claims are edited in Medisoft. 7.6 Explain how to change the status of a claim.

Learning Outcomes (Continued) 7-3 When you finish this chapter, you will be able to: 7.7 List the steps required to submit electronic claims in Medisoft. 7.8 Describe how to add attachments to electronic claims.

Key Terms 7-4 filter navigator buttons Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud. Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.

7.1 The Role of Claims in the Billing Process 7-5 Once the services a patient has received from a provider have been entered into the PMP, the next step is to create insurance claims Most important document for correct reimbursement Communicate information about a patient’s diagnosis and procedures and the charges to a payer Learning Outcome: 7.1 Describe the role of claims in the billing process. Page: 216 Teaching Notes: Claims need to be “Clean”. Clean claims—claims with all the information necessary for payer processing. Errors may cause the claim to be delayed or denied. Rejected claims can cost the practice twice as much which results in reduced cash flow. Claims that are not paid in full have a negative effect on the practice’s cash flow.

7.1 The Role of Claims in the Billing Process (Continued) 7-6 The HIPAA standard transaction for electronic claims is the HIPAA X12 837 Health Care Claim or Equivalent Encounter Information (837P). The paper format is known as the CMS-1500 claim form. Learning Outcome: 7.1 Describe the role of claims in the billing process. Page: 216 Teaching Notes: Almost all claims are sent electronically Both types of insurance claims are prepared in the practice management program.

7.2 Claim Management in Medisoft 7-7 Claims are created in the Claim Management area of Medisoft Claim Management dialog box Learning Outcome: 7.2 Discuss the information contained in the Claim Management dialog box. Pages: 216-220 Teaching Notes: They are also edited and submitted for payment here. Created from transactions. Can either be printed and mailed or transmitted electronically.

7.2 Claim Management in Medisoft (Continued) 7-8 The upper-right hand corner of the Claim Management dialog box contains five navigator buttons Navigator buttons simplify the task of moving from one entry to another Learning Outcome: 7.2 Discuss the information contained in the Claim Management dialog box. Pages: 216-220 Teaching Notes: The bottom of the Claim Management dialog box contains a number of buttons that are used for various functions. Review each of these. Navigator buttons

7.3 Creating Claims 7-9 The Create Claims button in the Claim Management dialog box opens the Create Claims dialog box Create Claims dialog box Learning Outcome: 7.3 Demonstrate how to create claims in Medisoft. Pages: 221-223 Teaching Notes: This dialog box provides several filters to customize the creation of claims.

7.3 Creating Claims (Continued) 7-10 A filter is a condition that data must meet to be selected The Create Claims dialog box uses these filters: ▪ Transaction dates ▪ Location ▪ Chart numbers ▪ Assigned ▪ Primary insurance ▪ Attending ▪ Billing codes ▪ Enter Amount ▪ Case indicator Learning Outcome: 7.3 Demonstrate how to create claims in Medisoft. Pages: 221-223 Teaching Notes: Any box that is not filled in will default to include all data, and claims with any entry in that box will be included.

7.3 Creating Claims (Continued) 7-11 Once claims are created, they are listed in the Claim Management dialog box, with a status of Ready To Send Learning Outcome: 7.3 Demonstrate how to create claims in Medisoft. Pages: 221-223 Teaching Notes: Do exercise 7-1.

7.4 Locating Claims 7-12 Medisoft’s List Only feature selects only those claims that meet specified criteria, such as: Chart number Date created Insurance carrier EDI receiver Billing method Billing date Batch number Claims status Learning Outcome: 7.4 Describe how to locate a claim that has already been submitted. Pages: 224-227 Teaching Notes: Sometimes it is necessary to select and view specific claims that have already been created. For example, any claims prepared for submission to an insurance carrier must be selected and then reviewed for completeness and accuracy. In addition, all claims that have been rejected by insurance carriers are selected and reviewed before resubmission. To locate these specific claims you use the List Only feature.

7.4 Locating Claims (Continued) 7-13 The List Only Claims That Match dialog box Learning Outcome: 7.4 Describe how to locate a claim that has already been submitted. Pages: 224-227 Teaching Notes: Do exercise 7-2

7.5 Editing Claims 7-14 To edit a claim, first select it in the Claim Management dialog box, then click the Edit button to display the Claim dialog box Learning Outcome: 7.5 Discuss how claims are edited in Medisoft. Pages: 227-231 Teaching Notes: This feature allows claims to be reviewed and edited before they are submitted to insurance carriers for payment. The more problems that can be spotted and solved before claims are sent to insurance carriers, the sooner the practice will receive payment. Edit button

7.5 Editing Claims (Continued) 7-15 Information can be edited on the five tabs of the Claim dialog box Five tabs Learning Outcome: 7.5 Discuss how claims are edited in Medisoft. Pages: 227-231 Teaching Notes: The top section of the Claim dialog box lists the claim number, the date the claim was created, the chart number, the patient’s name, and the case number which cannot be edited. Do exercise 7-3

7.6 Changing the Status of a Claim 7-16 When claims are transmitted electronically, the Claim Status for each claim automatically changes from Ready To Send to Sent Claim statuses can be changed manually in the Change Claim Status/Billing Method dialog box Learning Outcome: 7.6 Explain how to change the status of a claim. Pages: 231-232 Teaching Notes: Do exercise 7-4

7.7 Submitting Electronic Claims 7-17 To submit electronic claims in Medisoft Select Revenue Management from the Activities Menu The Revenue Management window opens Learning Outcome: 7.7 List the steps required to submit electronic claims in Medisoft. Pages: 232-236 Teaching Notes: Timely submission of claims is important to the cash flow of the practice.

7.7 Submitting Electronic Claims (Continued) 7-18 Select Claims on the Process menu of the Revenue Management window A list of claims ready to be sent is displayed Click Check Claims and the EDI receiver to perform an edit on the claims The Send button is used to submit the claims Learning Outcome: 7.7 List the steps required to submit electronic claims in Medisoft. Pages: 232-236

7.8 Sending Electronic Claim Attachments 7-19 The EDI Report area within the Diagnosis tab of the Case dialog box indicates when an attachment will accompany the claim and how the attachment will be transmitted The EDI Report area contains three boxes: Report Type Code Report Transmission Code Attachment Control Number Learning Outcome: 7.8 Describe how to add attachments to electronic claims. Pages: 237-239 Teaching Notes: The EDI Notes box can be used for entering extra information for procedures and diagnoses that might be required by the patient’s insurance carriers to process the electronic claim.

7.8 Sending Electronic Claim Attachments (Continued) 7-20 The EDI Report area informs the payer of the presence and status of any attachments Learning Outcome: 7.8 Describe how to add attachments to electronic claims. Pages: 237-239 Teaching Notes: Applying Your Skills EDI report area