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. To view the whole history of changes and notes related to a claim, click on this button. This shows the whole cycle of the claim from submission, archive, edit, re-submission, etc. It also shows any notes you have added to this claim. 

• To add notes, enter the information in the Add Notes field on the bottom and then click   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. 

Please note that 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 the rejection, it will provide which of the three entities the rejection is generating from, and provide the specific event that is causing the rejection.

Example of a Claim rejected at the Claim.MD Level

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 the 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   Add Note/Reminder  button. Clicking Now option for example, will immediately put the reminder on the Manage Claims list. Clicking "in 1 week" will make the reminder display in 1 week from the date you set it. 

Analyzing the Rejection Reason

If you want to investigate a rejected claim, checking the claim history is the best way to start your research. Understanding why a claim was rejected is crucial for determining the appropriate course of action. Some common reasons for claim rejection include:

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

To get a deeper understanding of any issues involving claim errors, it is best to select the Show Notes / History button  on the bottom right of the View/Edit claim screen. You will notice that there will be in red a REJECT event or reason. In the Claim History, a reason for rejection is given in in red letters:

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. Beginning in 2018, greater levels of specificity were available thereby making T1490 no longer effective. 

In this case, to correct the invalid data, the provider would need to choose a code in the T1490 family (meaning code out to a greater level of detail), before resubmitting the claim.

Level of Rejection

The claim flow path consists of several stages. 

1. It starts at with the the claim biller/provider, where the claim is initiated.
2. It then goes through the Claim.MD stage for processing. 
3. Afterward, it proceeds to the payer's Electronic Data Interchange (EDI) for further handling. 
4. The final step is the payer adjudication, which involves the payer's decision regarding the claim's approval or rejection.
   This is the sequence of steps, Clinic -> Claim.MD -> Payer EDI -> Payer Adjudication

Users are advised to contact the payer's Electronic Data Interchange (EDI) department to inquire whether the claims are in the queue to be processed. This department can provide valuable insights regarding the status of the claims.

An issue can arise when the payer rejects a claim at their EDI level. In the "Show History / Notes" section, there's an acknowledgment from the payer, but no Electronic Remittance Advice (ERA), and the claim is returned as rejected. In such instances, less experienced billing staff may mistakenly contact the payer/provider customer service department, believing the claim was never received by the payer. Consequently, the payer may contact Claim.MD to inquire why their claims aren't being transmitted. However, in the claim history, Claim.MD can demonstrate that the claim was indeed sent but was rejected at the payer's EDI level. 

For resolution, it's essential to engage with the payer's EDI department, as they handle correction processes in such cases, rather than involving the payer's adjudication or Electronic Remittance Advice (ERA) department. The payer's EDI department should be the primary point of contact to troubleshoot the claim transmission issue.

Smart Edits

Troubleshooting Transmission Errors using Show History / Notes

Working Backwards: When searching for the claim, it's often helpful to work backward from the most recent ID you have. Start with the last 'payer-assigned' ID, as it is the most current, and move up the history from there.

Wrong Division Check: If, after following these steps, you are still unable to locate the claim when talking to the payer's support team, consider the possibility that you might be in the wrong division or department. Double-check the division and ensure you are contacting the correct entity 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.
   
3. 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. Keep in mind that 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 to see if 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.

Claim History Events

Here is a table of common events found in the Show History / Notes window:

Events	Definitions
Uploaded in File	Claims submitted as part of a batch upload, consolidating multiple claims into a single file. A file link directs users to the list of claims in the upload, showing details and the format used (e.g., 837, CSV) for easy tracking and management.
Claim ready to transmit	The claim is completed and prepared for electronic transmission to the payer.
Transmit # to Transmit in file	A specific number assigned to the claim during the transmission phase.
Claim acknowledgement	Confirmation received from the payer that the claim has been successfully received.
EFT/Check #	A unique number linked to an Electronic Funds Transfer (EFT) or check issued for a claim payment. The EFT/Check # link provides direct access to individual claims associated with that specific account number (PCN/Account Number). The Full ERA link leads to the complete Electronic Remittance Advice (ERA) document, listing all EFT/Check numbers included in that ERA.
Reject	The claim has been denied by Claim.MD, a third-party clearinghouse, or the payer, typically due to errors, missing information, or non-compliance with submission guidelines.
Claim Made Invalid	The claim has been rejected or marked as invalid due to errors, missing information, or non-compliance with payer requirements.
WARN:	A warning indicating a potential issue with the claim, such as data flagged by the National Correct Coding Initiative (NCCI) or other data that seems unusual or unlikely, requiring further review or correction.
Smart Edit	An automated process, typically initiated by the payer, that reviews submitted claims and identifies potential issues, suggesting edits or corrections to ensure the claim meets compliance and accuracy standards before processing.
Associated with another claim	Refers to secondary claims that are connected to a primary claim, typically indicating coordination of benefits where the secondary claim relies on the outcome or information from the primary claim for processing and payment. Clicking on the link will bring you to the associated claim.
Notes added	Additional information or remarks have been appended to the claim, providing context, clarifications, or necessary details to assist in the processing, review, or adjudication of the claim.
Changed	An update or modification to the claim, often involving adding, removing, or correcting details. Example: "Changed "Insured Address 2" field from X to Y." If this change was made in error or needs to be reverted, an "Undo Changes" link is provided to reverse this specific update to its prior state.   Remember: Any changed/uploaded claims that share the same PCN/Account Number will simply update the claim, not create a whole new claim. See this article: How does Claim.MD decide when to update a claim record, or create a new one?
Alert	A notification indicating a potential issue with the claim, such as a missing receipt, missing Electronic Remittance Advice (ERA), or other critical information required for processing.

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