1. CHAPTER © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 7 Creating Claims

2. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes 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. 7-2

3. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) 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. 7-3

4. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms filter navigator buttons 7-4

5. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

6. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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.

7. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 7.2 Claim Management in Medisoft 7-7 Claims are created in the Claim Management area of Medisoft Claim Management dialog box

8. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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 Navigator buttons

9. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

10. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

11. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

12. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

13. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 7.4 Locating Claims (Continued) 7-13 The List Only Claims That Match dialog box

14. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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 Edit button

15. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 7.5 Editing Claims (Continued) 7-15 Information can be edited on the five tabs of the Claim dialog box Five tabs

16. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

17. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

18. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

19. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 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

20. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 7.8 Sending Electronic Claim Attachments (Continued) 7-20 The EDI Report area informs the payer of the presence and status of any attachments EDI report area