Transmitting and Approving Claims in Claim.MD

Claim.MD serves as a comprehensive platform for managing medical claims, and the transmission of documents, specifically medical claims, is a fundamental component of healthcare operations. Claim.MD provides four primary pathways for transmitting documents, two of which involve utilizing SFTP (Secure File Transfer Protocol) and API (Application Programming Interface). These methods facilitate the secure transfer of data from healthcare entities, including Practice Management Systems (PMS) and billing software, to Claim.MD for subsequent processing and submission to payers. Additionally, users have the flexibility to manually upload batch files or directly enter claims within the Claim.MD system. In this lesson, we will delve into these four transmission methods and provide insights on how to approve the transmission of claims within the Claim.MD platform.

SFTP (Secure File Transfer Protocol):

SFTP is a secure and widely used protocol for transferring files and data over a network. In the context of Claim.MD, healthcare organizations typically have a module within their PMS (Practice Management System) or billing software to input and compile claim data. This data is then sent to Claim.MD via SFTP. To do this, follow these steps:

a. Prepare the claim data in your PMS or billing software.

b. Use SFTP to securely transfer the claim data to Claim.MD.

c. The data will be received and processed by Claim.MD.

Please see this SFTP article to learn more about this method of interfacing data with Claim.MD.

API (Application Programming Interface):

API is a protocol that allows different software applications to communicate and exchange data. Claim.MD offers an API that enables seamless integration with PMS and billing software. Here's how to use the API for transmitting data to Claim.MD:

a. Integrate your PMS or billing software with Claim.MD using the provided API.

b. Once integrated, data is transferred automatically between systems.

c. The data will be processed by Claim.MD without manual intervention.

Please see this API article to learn more about this method of interfacing data with Claim.MD.

Manually Uploading of Claims:

In some cases, users may need to manually upload claims into Claim.MD. This method is useful when you have a PMS or billing software that can generate a batch of claims generated in a universally recognized format, such as X12, CSV, XML, etc. Here's how to manually upload claims:

a. Generate a batch file of multiple claims in a universally recognized format using your PMS or billing software.

b. Save this file in a folder or drive for easy access. The specifics for this step should be outlined by the PMS or billing software guidelines.

c. Navigate to the Upload Files page located in the left navigation menu in Claim.MD. The Upload Files page is where you can upload and parse these files into the proper format for transmission to payers. A list of supported formats is available on the Upload Files page for reference.

d. Upload the batch file in the accepted format. Most systems generate claims in the X12 format, which is widely recognized in the medical industry. However, some systems may produce batch files in CSV or XML formats.

For more detailed information on this method of transmission, please refer to the article on Upload Files.

Directly Entering Claims:

Claim.MD also offers the convenience of directly entering claims into the system without the need for third-party software. Here's how to create and submit claims directly within Claim.MD:

a. Go to the Manage Claims page in the left navigation menu in Claim.MD.

b. Click on the button on the top of the screen.

c. You can choose whether to use a pre-existing template created previously or create a claim from scratch.

d. Fill in the necessary details and information for the claim.

e. Review the claim for accuracy and completeness.

f. Once you're satisfied, save and submit the claim for processing.

Pending Approval Notification:

When data is received by Claim.MD, it may be held in a "Pending Approval" status. Users need to be aware of these pending claims to ensure they are transmitted accurately to payers. Here's how to find and manage claims in the "Pending Approval" status:

a. Navigate to the Manage Claims page in the left navigation menu.

b. Look for the green claim form icon with the title Pending Approval.

c. The notification will display how many claims are awaiting approval. In the example below, it states that there are 51 held claims waiting for approval to transmit.

Approving Claims for Transmission:

Depending on your organization's internal billing procedures, you may want to have individual users or administrative personnel review and approve the transmission of claims. To approve the transmission of held claims, follow these steps:

a. Click on the View Claims button on the very right of the Pending Approval notification.

b. Review the claims to ensure accuracy and completeness.

Adding Additional Columns for Viewing / Sorting Claims

On the top right of the Claim List, there is a Settings icon . When this is selected, a Select Fields window will pop-up.

1. From here, select/unselect the checkboxes next to the desired data to add/remove from the Claim List. 
2. Click Save once the data is selected.
   
   More Information

   When selecting fields to add to the columns on the claim list for review, it's advantageous to include elements that are commonly missed. For example, make sure to incorporate fields for prior authorizations, procedure and modifier codes, and, in the case of certain clinics, distinguish between the rendering and billing providers. Including often overlooked fields in the claim list columns is beneficial because it streamlines the review process, improves accuracy, reduces errors, and ensures consistent adherence to payer requirements, ultimately leading to more efficient and effective claim management.
   
   
3. In the Claim list, start viewing and sorting by the desired data columns. 

c. Approve the transmission of claims by clicking the Approve Transmit button.

d. A pop-up will confirm the number of claims marked for transmission (e.g., "51 claims are marked to transmit"). Click OK to clear the pop-up.

Turning Off Transmit Approval Required

Conclusion:

Transmitting documents, such as medical claims, in Claim.MD is essential for seamless healthcare billing and reimbursement. SFTP and API are reliable methods to transfer data from your PMS or billing software to Claim.MD. Remember to monitor the "Pending Approval" notification and ensure that claims are reviewed and approved before transmission to payers. This process ensures accurate and timely claim submissions, ultimately benefiting your healthcare organization.