Manage Claims

The Manage Claims page identifies claims that need attention. 

Video edited on Kapwing

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

Graphs

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

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   View Claims , 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.

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   Approve Transmit  button to submit the claims to the payer. 

A Results window displays showing the number of claims marked to transmit. Click OK  . 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.

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 View Claims.  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.

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 View Claims  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 Transmit Selected 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.

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