Claim Processing Overview

Once a patient's charges have been posted and a claim has been generated, the claim is ready to bill. The Claims tab is organized to reflect the various states a claim can be in before they are fully paid and closed. Use the Claims tab to locate, research, work and complete claims. Double-click any row on the tab to open the Claim Editor and view details about the claim. The toolbar at the top of the screen allows you to select all the claims, bill claims that are ready, resubmit claims, void claims, recalculate the status of a claim, apply a filter to the screen, locate a specific claim, or pass selected claim(s) to patient responsibility. Once a claim is billed (and is in the Billable category), the system validates the claim based on the payer settings to check if all the information needed to process the claim has been provided.

Filters limit what is displayed on the screen and make it easier to find particular areas you need to focus on. For example, if you want to resubmit all claims for a specific payer, use Custom Filters to display only claims for that payer. You can also use the Research button to limit the number of claims displayed.

Once claims have been billed, they can go through a number of different states before each charge fully explained and the claim completed. This is the Claim Life Cycle. Each charge within a claim has a life cycle of its own. Claims are organized into one of the categories (or states) below. Each category shows the number of claims currently in the category and the total amount of money that needs to be collected.

Category/Status Description
Ready There are no known issues with the charge. It is clean and ready for the next payer. Some charges within a claim have payer explanations but others do not. Ready status requires you open the Claim Editor and select the Bill check box on the charges with a Ready status.
Billable At least one of the claim's charges has a ready status and the Bill check box has been selected in the Client Editor. Once you click Bill, claims that are "not ready" move to the Not Ready category.
Not Ready The claim has not passed claim validation. Information needed to print forms CMS-1500 or UB-04 is missing or an incorrect ICD code version is being used. Double click the row to open the Claim Editor and determine what information is missing.
On Hold The claim was processed and has been denied by a payer. Refer to the EOB to resolve the issue.
Over Paid The amount of money received for the claim exceeds the total amount due for the claim. One or more of the charges has a credit balance at guarantor. This is a problem that needs to be resolved, for example a refund needs to be issued to the patient or money needs to get reallocated.
Under Paid At least one of the charges is not fully explained. (This could be primary, secondary, tertiary, or guarantor.) The amount of money received for the claim is less than the total claim charge amount.
Mixed The claim lines are at different payers. For example, one charge was completed by the primary payer and a co-insurance was applied to another charge, sending the second line to patient responsibility.
At Payer The charges have been submitted to a payer and payment or response from the payer is pending.
At Patient The charge was submitted to all payers (primary, secondary, and tertiary) and now is the responsibility of the guarantor.
Zero Balance All money has been received for the claim from each payer and the patient, or any outstanding balance on the claim has been written off. Claims in this category are still considered active so are included when running certain reports.

The table below provides detailed information on each column in the Claims tab.

Column Description
Claim Displays the system generated claim number.
Status Indicates the status of the claim. The status of a claim allows you to easily identify where the claim is and what action needs to be taken to move the claim to the next step. For example the primary payer has paid and the claim needs to be sent to the secondary payer. This column is only visible in the All Active Claims and All category.
Name Displays the patient's full name, as entered in the Client Editor.
Start Earliest date for any charge on the claim.
End Latest date for any charge on the claim.
Billed Total amount billed on the claim.
Paid Total amount from the payer.
Balance Balance amount due from the next payer.
ActivePayer Indicates who is currently responsible for the claim.
Version Date Displays the claim version number and identifies which payer the claim was submitted to as well as who submitted the claim. If this field is blank, the claim was created but never billed to a payer.
Version Note Indicates where the claim was billed to (primary, secondary, etc).
Primary Name Name of the primary payer designated in the Client Editor.
Secondary Name Name of the secondary payer designated in the Client Editor.
Tertiary Name Name of the tertiary payer designated in the Client Editor.

Related Topics:

Claim Processing Overview

Lifecycle of a Claim

Top 10 Reasons a Claim is Denied

Click here to move×