Manage Claims
  • 03 May 2024
  • 7 Minutes to read
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Manage Claims

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  • PDF

Article summary


The Manage Claims page identifies claims that need attention. 

Video edited on Kapwing

  • Click on Manage Claims on the left-hand navigation menu.


Recent Uploads Graph

Displays the most recent 7 days worth of uploaded or created claims activity. 

There are four categories of claims activity. Click on each category to view the individual claims in this category for the given day.

  • Rejected claims is in red. 
  • Transmitted claims are in green.
  • Pending Approval is in blue
  • Deleted claims are in yellow.

Recent Transmits Graph

Displays the last 30 days worth of claims that were transmitted.

These have two categories: Transmitted and Re-Transmitted. 

  • Transmitted means the claim was submitted once
  • Re-Transmitted means it was transmitted more than once

Claims that need attention

Important! Check with the Payer EDI Department!

Payers maintain two separate databases of patient claims, one maintained by their EDI department and the other by Provider Services or Customer Service. When your claim first arrives at the payer's portal, it's delivered to the EDI server and spends a fair amount of time running through the payer's front end edits, as much as a week or more for some claims.  During this time Provider Services is not aware of even the existence of the claim.  If the EDI department eventually rejects the claim, Provider Services will not know the claim was ever there, and they will tell you as much.

Once the claim clears these front end edits it's forwarded for adjudication.  It's during that time that the Provider Services database is updated and acknowledges the existence of the claim.  This is why, when you call them for an update, but prior to the claim having cleared all the front end edits, you may be told they never got the claim.

Rejected Claims

These are claims that have been rejected by Claim.MD, the payer's EDI vendor, or the payer's themselves. 

If there are rejected claims, click on   , and a list of red or yellow Claim Errors / Responses will display. Red errors are a rejected claim. Yellow errors indicate non-standard data that is likely to be rejected by the payer and should be reviewed before submission. 

  • Clicking on the individual claim in the list will open the View/Edit Claim page. Here is where boxes with the errors can be corrected with the explanation of the error on the bottom of the page. 

  • When a checkbox is checked next to a claim record in the Rejected Claims list, it is selected for an action. On the Rejected Claims screen, there is a Selected Actionsdropdown located in the upper right that offers a range of actions. 
    • One common action is the Transmit action, which is typically used to resend a rejected claim from Claim.MD after it has been reviewed and/or updated.
    • Re-validate will rescrub the claim checking all Claim.MD validation edits. If the claims passes validation it will be moved to pending approval, and if it does not pass it will be moved to the rejected claim list. Re-validate doesn't offer an opportunity to make changes, so it would be used if a payer previously rejected the claims, and has indicated they would accept a resubmission. It may also be used to check claims against any Claim.MD rule updates.
    • Submit Void will change block 22 on the claim to frequency code '8' (Void), then it will auto apply the payers earliest ICN # if one has been received and the field is not already completed on the claim form.

Claim Rejection Entities / Events

Please note that in 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

Click on the button to view History / Notes.

There are three columns: the date of the rejection, the entity from which the claim is generating the rejection, the specific event that it is causing the rejection.

Example of a Claim rejected at the Claim.MD Level

Archiving a Rejected Claim

Archiving in software involves systematically storing and removing inactive or resolved items from the current view, preserving access to historical data for reference or auditing purposes. Please be aware of the red  button at the bottom left of the screen . To archive a claim, click this button, and a pop-up window will appear seeking confirmation. Press "OK" to confirm, and the claim will be removed from the "Manage Claim" screen.

How to "un-archive" a claim 

To un-archive a claim, one should search for the claim from the Search page, click into the claim from the list and then click the Save Claim button on the top of the claim. This action will return the claim to its respective list, such as "Manage Claim - Rejected" or "Pending Approval."

If the "Transmit Approval" setting is turned off, ensure that any necessary changes are made before clicking Save Claim, as it will then go back to the payer.

Pending Approval

These are claims that Claim.MD did not find any issues with and are ready to be approved to be submitted to the payer. Click on     button to submit the claims to the payer. 

A Results window displays showing the number of claims marked to transmit. Click  . Any rejected claims by Claim.MD that need correcting will display immediately. Refresh the page to make sure there are no rejected claims via Claim.MD standards.

More Information

Claims can be enabled for automatic transmission from the Account Settings menu.

Missing Acknowledgement Alert

This alert means Claim.MD successfully transmitted these claims but has not received any response confirming receipt. Missing response alerts are configured by Claim.MD.  Please keep in mind, the time frame for missing acknowledgement is programmed different for each payer, but in most cases a response is expected within 48 hours.

These alerts mean something has failed in the standard communication process. If they receive this alert we are confident the claims transmitted to the payer, however something else may not be working correctly.

Some common reasons for a missing acknowledgement from the payer:

  • The payer may not have processed the claim file as expected.
  • The payer may have the claims but failed to return the status confirming receipt or rejection of the claims.
  • The payer may be experiencing a processing delay, and these messages could return later than normal
  • If the provider is not setup correctly in their system, some payers return no status messages

We recommend that if this occurs, the payer is contacted for confirmation that the claims were processed. If the payer has not received them within the next few days, it is recommended to re-transmit the claims.

To Re-transmit click .  All the claims that need to be re-transmitted should be selected in the View Claims list, select Transmit in the Selected Actions dropdown on the top right of the screen, and then select  Transmit Selected in the pop-up window.

More Information
If a payer acknowledgement, rejection, or ERA is returned these alerts will auto clear. Otherwise, they will remain on their list for a short period to take action.

ERA Alert

This alert means Claim.MD expected an ERA to be returned based on the time frame set in the ERA Alert Settings (Default is 30 days but may be modified). We recommend that you contact the payer and confirm the claims are being processed. If the payer has not received them you should consider re-transmitting the claims.

To Re-transmit click   make sure all the claims approved for transmit are selected, select Transmit in the Selected Actions dropdown on the top right of the screen, and select in the pop-up window.

Claim Reminder
This is a reminder that was added to individual claims by a Claim.MD user (See View/Edit Claims for how to add a reminder).

NCCI Alert

These are claims that have information that will possibly cause a rejection from a payer. This alert can be turned off in Account Settings.

Manage Claim Views

My Reminders / All Reminders

This dropdown will allow the user to see their own reminders or all user reminders.

Claim Grouping Dropdown

On the upper right corner of the Manage Claims page, there is a Claim Group dropdown to filtered by claim grouping (e.g. individual providers, specific rendering physicians, NPI, etc.). This is set up in the Claim Grouping tab on the Settings page.

Please remember that if this Claim Group is set to one provider in the dropdown, that it needs to be set to All again to view all the provider information in the Manage Claims page.

Claim Lists

Additional Claims List - displays claims that need attention such as rejected, pending, and alerts

Cleared Response Alerts (Past 30 days) - views pages that have alerts that have been cleared by clicking Remove Alert

Cleared ERA Alerts (Past 30 days)- views ERA alerts that have been cleared by clicking Remove Alert in the past 30 days

Archived Today/Yesterday - views claims that have been archived by a user using the archive function from the last two days

NCCI Alerts (Past 30 days) - views claims that have been flagged with non-standard data entered according to Medicare (and other payer's) guidelines

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