Daily Workflow Guide

This guide will cover the general workflow to review the status and results for claims that you have submitted to the payer.

Other daily tasks that you may want to review separately are the Eligibility and Uploading and Creating Claims guides.

Manage Claims

To review the results of claims already submitted or claims pending your approval to transmit, you'll want to visit the Manage Claims screen regularly. This page will show you any claims that require your attention. To get to this page, click on Manage Claims on your left navigation menu. 

That includes:

• Claims that have been rejected, either by Claim.MD or the payer.
• Claims that are missing important status updates or remittance details.
• Any claims that have arrived at a reminder date that you've defined.

Any time the payer or Claim.MD identifies a critical issue that will prevent a claim from processing, those claims will appear as Rejected Claims on the Manage Claims menu. These issues can either be corrected directly in Claim.MD by viewing and editing the data on the claim form, or they can be corrected in your billing software and resubmitted.

Claims that show up missing a confirmation or ERA from the payer will require some extra investigation. When this type of alert is returned, it means Claim MD is confident the claim was submitted to the payer successfully, but the payer has not given us the electronic updates we would expect in a timely manner.

In this situation it is often best to reach out to the payer directly, and verify those claims are in process. Sometimes provider credentialing issues, or changes in the ERA enrollment may prevent the payer from responding electronically.

View ERA

Next let's review the Electronic Remittance Advice, or ERA. ERA replaces a typical paper explanation of payment, and will explain what the payer has determined they will cover on a given claim. Remember that in most cases you'll only receive the electronic remittance if you have enrolled for those to return through Claim.MD.

To get to this page, click on View ERA on the left navigation menu. 

If your software does not auto download electronic remittance advice (ERA), then you will need to visit the View ERA screen to download or view the payment details that have returned from the payer.

- Each ERA is associated with a single check or EFT, unless the payer is denying all claims from that payment cycle.

- Use the drop down menu on the top right of the page to select ERA that are either waiting to be viewed and manually posted, or that have not been downloaded for auto posting yet.

- You can also use the search tools to look up past ERA from a specific payer, provider, or if the payer has given you a claim number, you can search using their payer assigned claim identifier.

Reporting

Reports are a great way to see an overview of all claim transactions in the system. To get to this page, click on Reporting on the left navigation menu. 

Remember that most reports will allow you to drill down to the specific claims associated with this graph, by clicking on the graph segment directly.  For example, let's look at the Payments & Adjustments report. Here we can find all claims that have received specific denial codes.

• Clicking on "OA-129" (Claim not covered by this payer) segment, will bring us to the claims that have received this denial reason in the specific time period.
• From here we can take further action, for example viewing and editing the claims will restore them to the Manage Claims menu to queue them resubmit to the payer.
• Or we can select multiple claims from the list to mark them to transmit to the payer again immediately.