Claim Grouping

The "Claim Grouping" feature allows you to create customized views and filters on the Reporting page, making it easier to group and manage claims based on your organization's needs when generating reports. 

Groupings can be customized based on specific criteria such as Rendering Provider NPI (National Provider Identifier), service dates, or claim status. Whether you're organizing claims for ERA payments or other purposes, this feature offers the flexibility to tailor groupings to meet your exact needs, helping to streamline your reporting process.

Claim Grouping Logic in Claim.MD

Claim.MD uses a simple logic system to filter and group claims. Here's how it works:

Same Key, Different Values = OR

If you use the same key with different values (e.g., payerid: 123 and payerid: 456), it means that either value will satisfy the condition. This is called an "OR" condition.

Example:

• payerid = 60064  
• payerid = 87726  

This translates to:

• (payerid = 60064 OR payerid = 87726)

The query will return claims where the payer ID is either 60064 or 87726.

Different Keys = AND

When you use different keys, each with its own value, both conditions must be true at the same time. This is an "AND" condition.

Example:

• payerid = 60064  
• status = paid  

This translates to:

• payerid = 60064 AND status = paid

The query will return only claims where the payer ID is 60064 and the status is "paid."

Combining OR and AND Conditions

You can also combine both "OR" and "AND" conditions in a single query. For example:

• payerid = 60064  
• payerid = 87726  
• bill_npi = 1234567890  

This translates to:

• (payerid = 60064 OR payerid = 87726) AND bill_npi = 1234567890

This means that the Payer ID can be either 60064 or 87726, but the Billing NPI must be exactly 1234567890.

This logic helps you create specific filters that meet your reporting needs efficiently.

The following are examples of how to create groups. In this case it is demonstrating how to create PAID and UNPAID ERA Groups.

To create a group for paid ERA:

1. From left navigation menu click Settings > Claim Grouping tab
2. Enter PAID in Group Name field.
3. Click the Add button next to the New Group Name field. 
4. Click the Matching Claim Value drop-down and select Errors & Messages.
5. Enter *PAID $*in the blank field next to Errors & Messages. 
   1. The information will be automatically saved when clicking anywhere on the screen.

To create a group for unpaid ERA:

1. Enter UNPAID in Group Name field.
2. Click the Add  button next to the New Group name Field. 
3. Select Errors & Messages the Matching Claim Value type in the dropdown.
4. Enter !*PAID $*in the blank field next to Errors & Messages dropdown.
   1. The ! character next to *PAID* tells the system to exclusively retrieve ERA that are not paid. 

Filter Report by Claim Group

Now that you have created your filters, navigate to Reporting in the left menu. 

1. Click New Report
2. Select your claim group in the drop-down (e.g. UNPAID). 
3. Click Generate.

How to Group Claims by User for Productivity Reports

Managers may want to group claims by specific users to monitor and evaluate productivity more effectively. You can easily set up user-based claim grouping by following these steps:

1. Request Configuration
   Begin by creating a support ticket with Claim.MD. In your request, ask to configure a productivity report grouped by users. Wait for confirmation from Claim.MD that this feature has been enabled for your account.
2. Set Up the Group in Claim.MD
   Once you've received confirmation, follow these steps in the page:
   • From left navigation menu click Settings > Claim Grouping tab
   • Enter a Group Name: In the "Group Name" field, type a label for the group (e.g., "User Productivity - [UserName]").
   • Add the Group: Click the Add button located next to the "New Group Name" field.
   • Select Special Identifier: From the "Matching Claim Value" drop-down menu, choose "Special Identifier."
   • Input Username: Enter the exact username of the user for whom you want to generate reports into the blank field next to the "Special Identifier" drop-down.
3. Automatic Save
   The information you enter will be saved automatically. No need to click a save button.

Run User Productivity Report

Now that you have created your filters for that specific user, navigate to Reporting in the left menu. 

1. Click New Report
2. Select the user claim group in the drop-down (e.g. UserName). 
3. Click Generate.