View/Editing Claims

The View/Edit Claims page is where to view and edit the data in individual claims.  This page displays anywhere the   View Claims  button is selected. For example, when reviewing Pending Approvals, Rejected Claims or Claim Reminders in the Manage Claims page, click the   View Claims  button in that section to see the individual claims that comprise that category. 

To review a list of claims, such as rejected claims, the easiest way is to use the Next (right) and Previous (left) arrows on the View/Edit Claim page. Clicking these arrows will load the next or previous claim in the list for review.

In addition, the Return to Claim List arrow  will navigate back to the claim list this claim was viewed from.

In the Claim list, start viewing and sorting by the desired data columns. 

Resizing Columns

On any grid, such as the Claim List, you can resize the header margins. Simply hover over the edge of the column until the pointer turns into a double arrow. Then, left-click and drag left or right to resize the column headers.

Approve Transmit

After saving a claim, it can be approved for transmission by administrative users or by users who have been granted this privilege under the Manage Users page.

Once you have finished editing and reviewing the claim do the following:

1. Click button.
2. A Claim Valid pop-up will display.  Click Approve Transmit Now link. If there are no errors, this action will transmit the claim. 
3. Check the Manage Claims page for any possible errors. 

Archiving a Claim

• Archiving a claim will remove the claim from the Manage Claims menu. This will still preserve access to the historical data for reference or auditing purposes. Use thebutton at the bottom left of the claim form to archive a claim.
• Claims can also be archived in bulk from a claim list by selecting "Archive" from the Selected Actions drop down menu.
  
  

Show History / Notes

Also notice the button on the bottom right of the claim. 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.

• After you add the note, make sure you click the button on the top of the page.

Warning

If you do not click the button, a pop-up box will appear asking, "Leave Site? Changes you made may not be saved." Click "Cancel" if you want to save your notes by clicking the button. If you choose "Leave," your notes will not be saved.

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 it 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. 

Clearing Reminders from Manage Claims Page

1. Go to the Manage Claims page.
2. Find the specific claim and click the button.
3. Click the Clear My [Reminder Date] Reminder  button to remove the reminder.
    

Institutional Claims

For institutional claims, to enter the facility information, navigate to the claim form. At the bottom of the Billing Provider section (Box 1), you’ll see a link labeled "Show Facility Name/Address." Click on this link, and a field will appear where you can enter the facility's name and address information. This step is necessary for accurately reporting the facility where services were rendered.

Adding Diagnosis Code and Date of Service

1. In Box 21, review/edit the diagnosis code(s). If more than one code needs to be entered, do that here. 
2. In Box 24, add the Date of Service (type in the date ##/##/### or use the calendar feature).  Also add the Procedure code, Diagnosis Reference, and Units.  
3. Click  button on top of page when finished.

Adding Additional Charges

If a second service line is needed, click the Add Charge button and it will add a second line.

Deleting Charges

• To delete a service line efficiently, start by deleting the From Date for the line to be removed. 
• With the cursor in that field, press the TAB key to navigate to the next field in the line, then use the DEL key to delete that information. 
• Repeat this process until you reach the end of the line. 
• All the fields in that line should now be blank. 
• Upon saving, the entire line will be removed.

Additional Narrative

The Additional Narrative field is commonly employed for unspecified codes in procedures and National Drug Code (NDC) classifications, enabling users to directly input text. This facilitates the inclusion of additional details for drug names and measurements when specific codes are unavailable, ensuring accurate documentation for insurance claims. For instance, users can describe a surgical tray containing five cotton swabs and two needles without explicitly provided codes, enhancing comprehensive record-keeping for procedures and drug-related items.

Attachments

Please note, not all payers or their claim submission trading partners allow attachments. 

Here is a link to those payers which currently allow attachments:

Payers Which Currently Allow Attachments

Once a claim is created or uploaded to one of the payers in the list above, there will be an Attach Documents link at the top of the claim's form in Claim.MD.

1. Click on the Attach Documents link. 
2. Click on Select A File.
3. Select the file from your local drive.
4. Close the Attach Document Window.
5. The link will now display the number of documents attached.
6. Be sure to select the appropriate Attachment Type.

Other Actions

The Other Actions dropdown performs actions relating to the claim such as Manage Appeals, Manage Templates, and Check Eligibility.

Manage Appeals

Selecting this option will immediately display a separate window that provides options for appeal forms and the ability to attach the 1500 Claim Form, ERA, and/or Claim History to the appeal. Additional files can be attached to the appeal using the   Select Files...  button. When finished selecting options and attachments, click   Add Note/Reminder .

• Select specific payer's appeal form or a general claim appeal form from the dropdown. 
• Review the information in the form to ensure this information is accurate in the blue boxes. Any red boxes (like comment boxes), is required information that must be entered. 
• Notice that any additional docs (like a paper version of the original claim or ERA) can be attached if those were options were selected. Click   Continue  when all the appeals information is entered and reviewed. 

Appeal Submission Methods

Choose your Submission Method:

1. Send Electronic Appeal:  In the circumstance where the payer accepts electronic appeals, a Send Electronic Appeals option will appear, accompanied by a field designated for the Payer Claim # (ICN). Conversely, if this method is not displayed, this indicates that the payer does not accept electronic appeals. Once the payer claim # is entered, click the Send Electronic Appeal button.
   
2. Send 1st Class USPS: This method means that Claim.MD will print out and send through 1st Class USPS all the claim information to the payer.
   Please Note

   Additional fees may apply for this service.
   1. For this method, select the default payer address in the dropdown or enter the address information in the Mail TO field. 
   2. Click   Send Mail when completed.
      
3.  Send Fax: In this method, enter the fax number and select the   Send Faxbutton. Claim.MD will send the fax to the Payer.
   Please Note

   Additional fees may apply for this service.
   1. An Appeal Status window will display the Fax To number, the attempts and the status if it was sent, failed, or aborted. The faxed appeal can be viewed by clicking the View button.
      
4.  Manual Appeal: This method is meant for the user to download the appeal packet and send to the payer manually.
   Click Manual Appeal to download the PDF and print out or email the packet manually.
   

Manage Templates

Templates can also be created in the View / Edit screen, which can save time when entering repetitive provider data directly into the system. 

To create a claim template, 

1. Click the button from the Manage Claims page.
   
2. Enter the data you want to be part of the template. Often this is Box 33 (Billing Provider) Tax ID, and other provider information.
3. Click the  button on the top of the form.
4. Select Manage Templates from the Other Actions dropdown menu. This will open the Template Manager window.
   
5. Enter a name for the template and click   Create New Template. The template will be saved in the Claim Template list. This means that when creating a new claim, the template will be available in the "Claim Template" dropdown field for selection.
   

Steps for using claim template:

1. Click button on the top of Manage Claims page page.
2. Select the template you want in the Claim Template dropdown (e.g. Test) 
3.  Enter a Patient Name and Service Date. If the patient is recognized from a previous claim, then it will show up on the list. The patient information and service date will be copied over to the claim.
   
4. Click Create Claim button. 
5. All the information from the template will be populated into the new claim. Edit and add information if necessary before submitting the claim.

Check Eligibility

Eligibility for patients can be checked from the View/Edit Claim page as well. Selecting this action will populate the Provider, Payer, and Patient Information fields in the Eligibility section automatically. This makes it easy to find a patient without having to lookup the patient's information and entering it from scratch in the Eligibility page. 

Steps to check Eligibility from View/Claim page. 

1. Select Check Eligibility in the Other Actions dropdown. 
2. The system will automatically display the Eligibility page with the Provider, Payer, Eligibility Information and Patient Information populated. 
3. Click the   Check Eligibility  button and look on the right hand side to view the eligibility information for this patient.

Sending Claims by Fax or Mail

Sending a claim by fax or mail is straightforward. 

To send a claim by fax:

1. If the payer accepts faxed claims, obtain their fax number and modify the payer ID to FAX01 to send the claim.
2. Add the payer's fax number in the Address 2 field. 
3.  *Optional : Once you change the payer ID to FAX01 or PAPER, there will be an "attach documents" link at the top of the claim if additional document needs to be sent.
4. Click on the Printer icon  to the very top right of the screen.
5. From the Claim Form dropdown, make sure Print Claim With Form is selected. 
6. On the Print Claim window, click Create PDF button.
7. A PDF window will generate with the paper version of the form. From here, the document can be printed and faxed.

 Faxing Claims: Page Limit and Procedures Guidelines

Our faxing system has a maximum capacity of 30 pages per transmission. When faxing claims, it's crucial to consider the page limitations to ensure successful and efficient processing. Below are important guidelines to follow when submitting claims via fax:

1. Page Limit:
   • The maximum number of pages allowed for outgoing fax transmissions is 30.
   • Each claim submission comprises two pages, including both the front and back views.
   • Claims with more than six procedures may require additional front/back pages, adjusting the overall page count accordingly.
2. Page Allocation for Claims:
   • For claims with six procedures or less, the total faxed pages should not exceed 28.
   • This accounts for the standard two-page allocation per claim and accommodates the possibility of additional pages for claims with more than six procedures.

By adhering to these guidelines, you ensure that your faxed claims fall within the specified page limits, facilitating seamless processing and minimizing potential issues. 

To send a claim by mail:

1. If the payer accepts paper claims, enter the word PAPER as the payer ID. 
   1. If the claim was uploaded to Claim.MD, the mailing address will be what was uploaded from your system. 
   2. If the claim has been manually entered, the payer address needs to be entered. Please note, Claim.MD does not maintain a list of payer addresses.
2. Click on the Printer icon  to the very top right of the screen.
3. From the Claim Form dropdown, make sure Print Claim With Form is selected. 
4. On the Print Claim window, click Create PDF button.
5. A PDF window will generate with the paper version of the form. From here, the document can be printed.

Get Help

In the View/Edit page, you'll find a button at the top of the screen. Clicking this button generates a ticket, which will be displayed on the right side of the screen. Creating a support ticket here ensures that it is directly associated with the current claim. This feature is designed to streamline the process, saving time by avoiding the need to navigate back and forth to look up information for a support ticket. It is advisable to use this button specifically when creating tickets for individual claims.

• In the blank field under Describe your issue, enter the issue you need addressed. If you click   Submit Support Request  the request will be sent to the support team and assigned a ticket number. They will reply back in both the internal ticket of that claim as well as being sent to the email provided in the My Information section of the settings page. 
• To view the ticket directly in Claim.MD, navigate to Support Tickets on the left-hand navigation menu. This will display a list of open tickets. Click on the ticket to view any messages from support and reply to them in the green response field.
• Navigate back to the View/Edit Claim screen. If someone replies in the ticketing system, a red cross with arrow pointing to the Get Help menu will display to indicate you that there is a new reply that has not been viewed yet. Click the button to view the ticket from this screen and reply if necessary.