1. CHAPTER © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7 Creating Claims

2. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to: 7.1 Describe the five most common types of health insurance plans. 7.2Describe the role of claims in the billing cycle. 7.3 Discuss the information contained in the Claim Management dialog box. 7.4 Demonstrate how to create claims in Medisoft. 7.5 Describe how to locate a claim that has already been submitted. 7.6Discuss how claims are edited in Medisoft. 7.7 Explain how to change the status of a claim. 7-2

3. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (continued) When you finish this chapter, you will be able to: 7.8 List the steps required to submit electronic claims in Medisoft. 7.9Describe how to add attachments to electronic claims. 7-3

4. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms capitation clean claims CMS-1500 coinsurance copayment deductible filter health maintenance organization (HMO) high-deductible health plan with savings option (HDHP/SO) indemnity plan 7-4 managed care medical necessity navigator buttons payer point-of-service (POS) plan policyholder preferred provider organization (PPO) premiums X12 837 Health Care Claim or Equivalent Encounter Information (837P)

5. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.1 The Basics of Medical Insurance Policyholder is a person or entity who buys an insurance plan, the insured. Premiums are the periodic amount of money the insured pays to a health plan for insurance coverage. Payer is a private or government organization that insures or pays for healthcare on behalf of beneficiaries. Indemnity plans are also known as a fee-for- service plans; they reimburse the policyholder for a percentage of covered medical expenses. 7-5

6. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.1 The Basics of Medical insurance (continued) Government plans include: –Medicare – federal plan for those 65 and over, people with disabilities and end-stage renal disease, and dependent widows –Medicaid – state and federally funded program that covers low income persons –TRICARE – government program for dependents of active- duty and retired military personnel –CHAMPVA – covers veterans with permanent service- related disabilities and their dependents, as well as surviving spouses and dependent children of veterans who died from service-related disabilities –Workers’ Compensation – covers persons with job-related illnesses or injuries 7-6

7. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.1 The Basics of Medical insurance (continued) Managed care is a type of insurance in which the carrier is responsible for both the financing and the delivery of healthcare. A preferred provider organization (PPO) is a managed care network of healthcare providers who agree to perform services for plan members at discounted fees. A health maintenance organization (HMO) is a managed system in which providers agree to offer healthcare to the organization’s members for fixed payments. 7-7

8. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.1 The Basics of Medical insurance (continued) A copayment is a fixed fee paid by the patient at the time of an office visit. Capitation is a payment made to a provider that covers each plan member’s healthcare services for a certain period of time. A point-of-service (POS) plan is a plan, combing features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network. A deductible is the amount due before benefits begin. 7-8

9. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.1 The Basics of Medical insurance (continued) A high-deductible health plan with savings option (HDHP/SO) is a type of managed care insurance in which a high-deductible plan is combined with a pretax savings account to cover out-of-pocket medical expenses. Coinsurance is a percentage of charges that an insured person must pay for healthcare services after payment of the deductible amount. 7-9

10. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.1 The Basics of Medical insurance (continued) 7-10 Enrollment in Employer-Sponsored Health Plans by Type, 2006 and 2011

11. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.2 The Role of Claims in the Billing Cycle Medical Necessity is treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner which is appropriate and is provided in accordance with generally accepted standards of medical practice. Clean Claims are claims with all the correct information necessary for payer processing. 7-11

12. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.2 The Role of Claims in the Billing Cycle (continued) X12 837 Health Care Claim or Equivalent Encounter Information (837P) is the HIPAA standard format for electronic transmission of a professional claim from a provider to a health plan. CMS-1500 is the mandated paper insurance claim form. 7-12

13. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.2 The Role of Claims in the Billing Cycle (continued) 7-13 Once the services a patient has received from a provider have been entered into the PMP, the next step is to create insurance claims. –The insurance claim is the most important document for correct reimbursement. –It communicates information about a patient’s diagnosis, procedures, and charges to a payer.

14. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.3 Claim Management in Medisoft 7-14 Claims are created in the Claim Management area of Medisoft. Claim Management dialog box

15. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.3 Claim Management in Medisoft (continued) 7-15 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. Navigator buttons

16. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.4 Creating Claims 7-16 The Create Claims button in the Claim Management dialog box opens the Create Claims dialog box. Create Claims dialog box

17. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.4 Creating Claims (continued) 7-17 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

18. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.4 Creating Claims (continued) 7-18 Once claims are created, they are listed in the Claim Management dialog box, with a status of Ready To Send.

19. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.5 Locating Claims 7-19 Medisoft’s List Only feature selects only those claims that meet specified criteria, such as: –Chart Number –Claim Created –Insurance Carrier –EDI Receiver –Billing Method –Billing Date –Batch Number –Claims Status

20. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.5 Locating Claims (continued) 7-20 The List Only Claims That Match dialog box

21. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.6 Editing Claims 7-21 Edit button To edit a claim, first select it in the Claim Management dialog box; then click the Edit button to display the Claim dialog box.

22. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.6 Editing Claims (continued) 7-22 Information can be edited on the six tabs of the Claim dialog box. Six tabs

23. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.6 Editing Claims (continued) 7-23 The EDI Note tab displays the electronic claim and contact information from the Comment tab of the case folder. EDI notes

24. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.7 Changing the Status of a Claim 7-24 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.

25. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.8 Submitting Electronic Claims 7-25 To submit electronic claims in Medisoft: –Select Revenue Management from the Activities Menu. –The Revenue Management window opens.

26. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.8 Submitting Electronic Claims (continued) 7-26 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.

27. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.8 Submitting Electronic Claims (continued) 7-27 List of claims ready to be sent, by EDI Receiver

28. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.8 Submitting Electronic Claims (continued) 7-28 List of claims after edits performed

29. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.8 Submitting Electronic Claims (continued) 7-29 Preview window with Claim Edits Report displayed

30. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.9 Sending Electronic Claim Attachments 7-30 The EDI Report area in the Diagnosis tab of the Case folder 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

31. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.9 Sending Electronic Claim Attachments (continued) 7-31 The EDI Report area informs the payer of the presence and status of any attachments. EDI Report area

32. © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7.9 Sending Electronic Claim Attachments (continued) 7-32 Transaction Entry dialog box with EDI Notes button highlighted