2 Learning Outcomes When you finish this chapter, you will be able to: 7-2When 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
3 Learning Outcomes (Continued) 7-3When 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.
5 7.1 The Role of Claims in the Billing Process 7-5Once the services a patient has received from a provider have been entered into the PMP, the next step is to create insurance claimsMost important document for correct reimbursementCommunicate information about a patient’s diagnosis and procedures and the charges to a payerLearning Outcome: 7.1 Describe the role of claims in the billing process.Page: 216Claims 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.
6 7.1 The Role of Claims in the Billing Process (Continued) 7-6The HIPAA standard transaction for electronic claims is the HIPAA X 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: 216Almost all claims are sent electronicallyBoth types of insurance claims are prepared in the practice management program.
7 7.2 Claim Management in Medisoft 7-7Claims are created in the Claim Management area of MedisoftClaim Managementdialog boxLearning Outcome: 7.2 Discuss the information contained in the Claim Management dialog box.Pages:They are also edited and submitted for payment here.Created from transactions.Can either be printed and mailed or transmitted electronically.
8 7.2 Claim Management in Medisoft (Continued) 7-8The upper-right hand corner of the Claim Management dialog box contains five navigator buttonsNavigator buttons simplify the task of moving from one entry to anotherLearning Outcome: 7.2 Discuss the information contained in the Claim Management dialog box.Pages: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
9 7.3 Creating Claims7-9The Create Claims button in the Claim Management dialog box opens the Create Claims dialog boxCreate Claimsdialog boxLearning Outcome: 7.3 Demonstrate how to create claims in Medisoft.Pages:This dialog box provides several filters to customize the creation of claims.
10 7.3 Creating Claims (Continued) 7-10A filter is a condition that data must meet to be selectedThe Create Claims dialog box uses these filters:▪ Transaction dates ▪ Location▪ Chart numbers ▪ Assigned▪ Primary insurance ▪ Attending▪ Billing codes ▪ Enter Amount▪ Case indicatorLearning Outcome: 7.3 Demonstrate how to create claims in Medisoft.Pages:Any box that is not filled in will default to include all data, and claims with any entry in that box will be included.
11 7.3 Creating Claims (Continued) 7-11Once claims are created, they are listed in the Claim Management dialog box, with a status of Ready To SendExercise 7-1 page 222Learning Outcome: 7.3 Demonstrate how to create claims in Medisoft.Pages:Do exercise 7-1.
12 7.4 Locating Claims7-12Medisoft’s List Only feature selects only those claims that meet specified criteria, such as:Chart numberDate createdInsurance carrierEDI receiverBilling methodBilling dateBatch numberClaims statusLearning Outcome: 7.4 Describe how to locate a claim that has already been submitted.Pages: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.
13 7.4 Locating Claims (Continued) 7-13The List Only Claims That Match dialog boxExercise 7-2 page 226Learning Outcome: 7.4 Describe how to locate a claim that has already been submitted.Pages:Do exercise 7-2
14 7.5 Editing Claims7-14To edit a claim, first select it in the Claim Management dialog box, then click the Edit button to display the Claim dialog boxLearning Outcome: 7.5 Discuss how claims are edited in Medisoft.Pages: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
15 7.5 Editing Claims (Continued) 7-15Information can be edited on the five tabs of the Claim dialog boxExercise 7-3 page 231Five tabsLearning Outcome: 7.5 Discuss how claims are edited in Medisoft.Pages: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
16 7.6 Changing the Status of a Claim 7-16When claims are transmitted electronically, the Claim Status for each claim automatically changes from Ready To Send to SentClaim statuses can be changed manually in the Change Claim Status/Billing Method dialog boxExercise 7-4 page 231Learning Outcome: 7.6 Explain how to change the status of a claim.Pages:Do exercise 7-4
17 7.7 Submitting Electronic Claims 7-17To submit electronic claims in MedisoftSelect Revenue Management from the Activities MenuThe Revenue Management window opensLearning Outcome: 7.7 List the steps required to submit electronic claims in Medisoft.Pages:Timely submission of claims is important to the cash flow of the practice.
18 7.7 Submitting Electronic Claims (Continued) 7-18Select Claims on the Process menu of the Revenue Management windowA list of claims ready to be sent is displayedClick Check Claims and the EDI receiver to perform an edit on the claimsThe Send button is used to submit the claimsLearning Outcome: 7.7 List the steps required to submit electronic claims in Medisoft.Pages:
19 7.8 Sending Electronic Claim Attachments 7-19The 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 transmittedThe EDI Report area contains three boxes:Report Type CodeReport Transmission CodeAttachment Control NumberLearning Outcome: 7.8 Describe how to add attachments to electronic claims.Pages: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.
20 7.8 Sending Electronic Claim Attachments (Continued) 7-20The EDI Report area informs the payer of the presence and status of any attachmentsLearning Outcome: 7.8 Describe how to add attachments to electronic claims.Pages:EDI report area