Computers in the Medical Office

Computers inthe Medical Office Chapter 7: Creating Claims

Creating Claims • Once the services a patient has received been entered into the practice management program, the next step is to create insurance claims. • The insurance claim is the most important document for correct reimbursement. • Claims communicate information about a patient’s diagnosis and procedures and the charges to a payer.

Creating Claims • HIPAA standard transaction for electronic claims is the HIPAA X12-837 Health Care Claim or Equivalent Encounter Information (837P). • Paper format is known as the CMS-1500 claim form.

Creating Claims • Claims are created in the Claim Management area of Medisoft

Creating Claims • When the Create Claims button is clicked, the Create Claims dialog box appears

Creating Claims • The Create Claims dialog box contains a number of filters claims, including

Creating Claims • Once claims are created, they are listed in the Claim Management dialog box, with a status of Ready to Send

Selecting/Filtering Claims • Medisoft’s List Only feature selects only those claims that meet specified criteria, such as: • Chart number • Date created • Insurance carrier • EDI receiver • Billing date

Editing Claims • If any claims need to be edited, simply highlight the claim in the Claim Management dialog box and click the Edit button

Editing Claims • In the Claim dialog box, changes are made to a claim, such as moving a transaction to another claim

Transmitting Claims • Claims are transmitted electronically to a clearinghouse, or directly to an insurance carrier

Transmitting Claims • The clearinghouse sends a report to the practice, to verify the claims that were transmitted

Transmitting Claims • The clearinghouse also sends an audit/edit report to the practice, which lists potential problems with claims • Corrections are made before the claims actually reach the insurance carrier

Computers in the Medical Office