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Claim Entry and Processing

Overview

Claim Entry is a web application designed specifically for entering and processing claim data. Claim Entry provides the capability of working with both CMS 1500 and UB claims.

Batch Menu

A batch is simply a collection of related claims, such as if you had a stack of claims on your desk to enter, or the claims may have been submitted around the same time electronically (EDI). All claims in a batch must be the same type, so if you have entered several 1500 claims and now have a UB, you will need to start a new batch to enter the UB claim.

Claim Entry opens with the Batch Menu (or Main Menu). This is the default screen when you are not directly working with a claim.

  1. Before working with any claims, you must select a group policy. Each group may have different rules and configuration, so the program needs to know this in advance prior to entering claims. If your account is specific to exactly one group policy, this will automatically be selected for you when opening the program.
  2. After entering your first claim, or after selecting an existing claim to process, the batch number for this collection of claims will be shown here. You may begin a new batch by clicking 'New', view recent batches you have entered with 'Entry Batches', or view batches with claims needing manual processing by clicking 'Processing Batches'.
  3. The batch list shows a list of claims and claims statuses for the current batch.
    • Immediately after entering a claim it will be BP (in-network Before Pricing) or OP (out-of-network Before Pricing). The system will reprice the claim within the next few minutes. See Common Claim Status Codes below for more information on claim status codes. You can click Reload to see when the claim status changes.
    • You can see basic claim info for the selected claim by highlighting a claim and clicking 'View Selected'.
    • If you want to complete the claim, and/or prevent the claim from exporting electronically (EDI), you can click the 'Print EOR' button.
  4. If you are already in a batch, and have claims showing in (3), you can highlight a claim and click this button to begin processing. Note that the claim must be in a status waiting for manual processing. See Common Claim Status Codes below for more information.
  5. Start a new UB claim. See Claim Entry. Note that after entering your first UB, only UB's may be entered until you start a new batch.
  6. Start a new 1500 claim. See Claim Entry. Note that after entering your first 1500, only 1500's may be entered until you start a new batch.
  7. To end the current batch and begin a new one, or to reprint a previous batch summary if you know the exact batch number, click this button. This will finalize the batch, meaning no further claims may be added to the batch. You should do this once after each batch/collection of claims have been entered.
  8. If you have received an email notification and know the exact claim you wish to process, use this button and enter the claim number to begin processing.
  9. Notes for the current claim. If the system has attempted to reprice the claim but was unable to do so, there may be notes here to help the processor understand why the claim did not auto-adjudicate.

Common Claim Status Codes

BP in-network before pricing
OP out-of-network before pricing
E in-network, adjudicated, before exporting
OE out-of-network, before exporting
C in-network, complete (claim has gone out EDI if applicable)
CO out-of-network, complete (claim has gone out EDI if applicable)
A in-network, waiting for manual processing (claim notes should help when processing)
OA out-of-network, waiting for manual processing (claim notes should help when processing)

See Also

start.txt · Last modified: 2014/05/20 15:19 by admin