Claim History

This article will explain the Claim History feature and how it will be your most effective tool in tracking and managing your claims.

Show History / Notes

Navigate to a claim from any claim list or claim search. Notice the  button on the bottom right of the claim screen. Click on this button to view the entire history of changes and notes related to a claim. This history includes submission, archive, edits, re-submission, and any notes added.

• To add notes, enter the information in the Add Notes field at the bottom and then click the Add Note/Reminder button.

If you do not click the button, a pop-up box will appear asking, "Leave Site? Changes you made may not be saved." If you choose to select "Leave", the claim note will still be saved if you go back into the history notes.

Show History / Notes is an extremely useful tool for investigating at what level the claim was rejected. A claim can be rejected from:

• Claim.MD
• Payer’s Trading Partner
• Payer Directly

After the date of rejection, the system will specify which of the three entities generated the rejection and provide details on the specific event causing it.

Viewing ERA from the Show History / Notes

1. Click on the Show History/Notes button.
2. Click on the EFT/Check# or Full ERA link to view the ERA.

Adding a Reminder

To add a reminder along with a note, click the Add Reminder dropdown on the bottom right of the Show History / Notes box, select the time period you want it to display in the Manage Claims section, and then click the Add Note/Reminder button.

Clicking Now will immediately put the reminder on the Manage Claims list. Selecting "in 1 week" will make the reminder display in 1 week from the date you set it.

To add a reminder along with the note, click the Add Reminder dropdown on the bottom right of the Show History / Notes box, select the time period for it to appear in the Manage Claims section, and then click the Add Note/Reminder button. Selecting Now will immediately add the reminder to the Manage Claims list, while choosing "in 1 week" will display the reminder one week from the set date.

Analyzing the Rejection Reason

If you need to investigate a rejected claim, checking the claim history is the best starting point. Understanding the reason for rejection is crucial in determining the next steps. Some common reasons for claim rejection include:

• Incomplete patient information.
• Incorrect coding or billing details.
• Discrepancies between the claim and patient records.
• Insurance eligibility issues.

To get a deeper understanding of claim errors, select the Show Notes / History button  on the bottom right of the View/Edit claim screen. You will see a red REJECT event or reason. In the Claim History, a rejection reason appears in red text:

REJECT: Diagnoses [T1490] is valid, but not for this date [10/13/2022].

This rejection code means that the use of T1490 ended when it became a "parent" code. Since 2018, more specific codes have been required, making T1490 obsolete.

To correct this, the provider needs to select a more detailed diagnosis code from the T1490 family before resubmitting the claim.

Level of Rejection

The claim flow follows several stages:

1. The claim process begins with the biller/provider, where the claim is created and submitted.
2. It then moves to Claim.MD for initial processing and validation.
3. After processing, the claim is sent to the payer's Electronic Data Interchange (EDI) for further evaluation.
4. The final step is payer adjudication, where the payer decides on claim approval or rejection.
   This follows the path: Clinic → Claim.MD → Payer EDI → Payer Adjudication

To track the status of a claim, contact the payer’s EDI department. They can confirm if the claim is in the processing queue and provide status updates.

If a claim is rejected at the payer’s EDI level, the "Show History / Notes" section will display an acknowledgment from the payer but no Electronic Remittance Advice (ERA). In such cases, billing staff may mistakenly assume the claim was never received. This can lead to confusion and unnecessary inquiries.

However, Claim.MD can verify that the claim was transmitted but rejected at the payer's EDI level.

Resolution: Always contact the payer’s EDI department to address claim transmission issues, as they handle corrections at this level rather than the payer's adjudication or ERA departments.

Smart Edits

Troubleshooting Transmission Errors Using Show History / Notes

Working Backwards: When tracking a claim, start from the most recent payer-assigned ID and move up through the claim history.

Wrong Division Check: If the claim cannot be located when speaking with the payer's support team, verify that you are contacting the correct division or department responsible for handling the claim.

Steps to Analyze Transmission Errors:

1. Access the "View/Claim" screen to review the claim's history and any associated notes with the  button.
2. User Upload: Confirm that the claim was indeed uploaded by a user. This step is essential to ensure that the error didn't occur at the initial submission.
   

• Transmittal Stage:Check the claim's history to locate the point at which it was transmitted. When you find this point, take note of the following:
  1. File ID: Verify if a File ID was generated by Claim.MD at the time of transmission. This is the first identifier associated with the claim.
     
  2. Payer-Generated Batch ID: Determine if the payer immediately assigned a claim/batch ID upon receiving the claim. Note that not all payers assign batch IDs at this stage.
  3. EDI Level Assignment: Understand that as the claim progresses through the Electronic Data Interchange (EDI) levels, it might be assigned a new ID. Track the most recent EDI level ID assigned.
     1. Acknowledgement: Check if the payer has assigned any acknowledgement, which indicates they have received the claim. Due to various divisions and trading partners that payers utilize, the claim may not be immediately visible to the person you are speaking to at the payer level. You may need to talk with that trading partner instead.
        

Payer Contact Procedure:

1. Contact Claims Adjudication: First, reach out to the claims adjudication department and inquire about the status of the claim using the most recent ID you have. If it's not found, proceed to the next steps.
2. EDI for Payer: Contact the payer's EDI department and provide them with the last known 'payer' claim/batch ID. They will help you search for the claim in their system.
3. Auto-Assigned ID: If the claim is still not found, provide them any auto-assigned ID from the time of transmission. This is the last resort to locate the claim.

By following these steps and tracking the history of the Claim/Batch IDs, you can systematically investigate potential transmission errors and ensure that you are reaching out to the right department for resolution.

Check ERA Associated with Claim

To check if an ERA is associated with a claim, click on the Show History / Notes button on the bottom right corner and search for the EFT/Check# 

Show History / Notes for Secondary Claims

• If there is a secondary claim, the Show History / Notes for the secondary claim will have a link in the Event column notifying that it is "associated with another claim". Click on the link to bring you to the primary claim associated with it.
• Similarly, the Primary claim will have a "New Claim Created from this Claim" link in its Show History / Notes. Click on this link to view the Secondary Claim.