Work Claims

  • Updated

Working open claims is the most important step in the revenue cycle. If open claims are not actively worked, an organization will not be able to recognize its revenue potential. The RCM is built to make this process simple, easy to follow, and effective. Let's review the different areas claims can be worked within the RCM!

In the Work Center

The Work Center can work on multiple claims for multiple patients simultaneously. It offers 15 filters, 13 columns of information, and 7 actions, allowing users to search, refine, and work on various claims simultaneously. Let's review those together! 

Workflow

    1. In the Work Claims section, click to update any desired filter dropdowns. 
    2. Next, update the Follow-Up Start and Follow-Up End date.
    3. Click Update.
    4. Click Download as Excel to generate an Excel list of filtered claims.
    5. Click the box next to the Claim ID to update the claim.
    6. Next, click Bulk Update Workflow/Notes.
    7. Under Update, select one or more of the following box(es):
      1. Claim Queue: This will update the claim(s) queue.
      2. Claim Status: This will update the system status of the claim(s).
      3. Assigned User: This will assign the claim(s) to a specific user.
      4. Follow-Up Date: This will update the next follow-up of the claim(s).
      5. Note: This will add a note to the claim(s).
      6. Claim State: This will open or close the claim(s).
    8. Finally, click Save to complete the process.

Filters and Buttons

  • Name Definition
    Organization/Practice/Facility Filter open claims by their associated Organization/Practice/Facility
    Claims Filter claims based on their assignment status
    HCPCS/CPT Filter claims by the procedure code
    Insurance Payer Filter claims by the current sequence payer
    Service Filter claims by the service rendered
    Insurance Payer Status Filter claims by the current payer status of the claim e.g. Accepted, Denied, Pending.
    Group By Determines how to group the filtered claims in the grey sections
    Sort By Determines the listed descending order of the filtered claims in the grey sections
    Queue Filter claims by the current system-assigned status
    Assigned to Filters show claims based on user follow-ups. Only claims assigned to you appear in the first option, while all claims, assigned or not, list under the second. The third option displays only claims without an assigned user. 
    Date Type Filter claims by the Follow-up Date or Date of Service
    Follow-Up Start/End Determines the date range of the listed claims
  • Name Definition Helpful Hints
    Claim ID This is the RCM-assigned claim number

    Click on the hyperlink to be redirected to the Work Claim screen.
    Patient This is the patient's first and last name Click on the hyperlink to be redirected to the Claims section of the patient's treatment episode.
    Subscriber ID This is the subscriber ID found within the patient's insurance set  
    Status This is the current payer status of the claim If the status shows Rejected, click the red text to display the reason.
    Services This is the name(s) of the service(s) on the claim  
    DOS Start and DOS End This is the first DOS and last DOS on the claim  
    Charges This is the sum of all charges on the claim This column does not account for expected rates
    Follow-Up This is the most recent follow-up date set for the claim  
    Last Action Date This is the last date any work was done on the claim  
    Days Outstanding This is the number of days the claim has been open This is calculated using the date of submission
    Assigned To This is who the claim is currently assigned to for follow-up  

In the Patient Profile

In addition to the Work Center, claims can be worked on individually within the patient's profile.

Workflow

    1. In the treatment episode of the patient's profile, click Insurance Billing > Claims. 
       
    2. Next, update the filters to generate the desired list.
    3. To update the claims in bulk, click the box(es) next to the Claim number.
    4. Click Bulk Update Workflow/Notes/Issues.
    5. Under Update, select one or more of the following box(es):
      1. Claim Queue: This will update the claim(s) queue.
      2. Claim Status: This will update the system status of the claim(s).
      3. Assigned User: This will assign the claim(s) to a specific user.
      4. Follow-Up Date: This will update the next follow-up of the claim(s).
      5. Add Note: This will add a note to the claim(s).
      6. Add Issue: This will add an Issue to the claim(s).
      7. Close Issue: This will close any open issues. 
      8. Claim State: This will open or close the claim(s).

    6. Finally, click Submit to complete the process.

Filters and Buttons

  • Name Definition
    Claims Filter instructs the system to locate claims based on their current disposition. This can include Open, Closed, or Voided.
    Date Type Filter claims based on the first DOS and last DOS on the claim.
    Start Date and End Date This filter is only available when the default Date Type has been changed.
    Sort By This instructs the system on how to display the claims. 
  • Name Definition
    Claim This is the RCM-assigned claim number.
    Service(s) This is the name(s) of the service(s) on the claim.
    Date(s) This is the first DOS and last DOS on the claim.
    Charges This is the sum of charges on a claim.
    Covered This is the sum of the covered charges on a claim.
    Balance This is what is currently owed on a claim.
    State This indicates whether the claim is open, closed, or voided.
    Status This is the last date any work was done on the claim.
    Queue This is the queue the claim is currently assigned to.
    Follow-Up This is the next follow-up day.
    Assigned User This is who the claim is currently assigned to for follow-up.
    Links CMS-1500/UB-04: Generates a pdf of the claim
    Payments: Opens the Payments tab within the Work Claim screen
    Resubmit: Allows a user to resubmit a claim without generating corrections
    PoTF: Generates a pdf copy of the Proof of Timely Filing
    Details This displays the ICN information, U/R information, and a breakdown of applicable payments.
    Issues This shows the issues with which the claim has been tagged.
    Notes This displays notes made by a user.

In the Work Claim Screen

The Work Claim screen allows a user to work on a claim individually. Let's review this section together!
 

Workflow

    1. In the Claims section, click the claim number to open the Work Claim screen.
    2. Click Workflow.
    3. Next, click Edit.

    4. In the Edit screen, update one or more of the following fields:
      1. Internal Control Number: This field will update the payer's claim number
      2. Claim Queue: This will update the claim(s) queue.
      3. Claim Status: This will update the system status of the claim(s).
      4. Assigned User: This will assign the claim(s) to a specific user.
      5. Follow-Up Date: This will update the next follow-up of the claim(s)
      6. Force Itemization: This will generate a correction that itemizes the claim. 
      7. Force Paper: This will force a correction that generates a paper claim.
         
    5. Finally, click Save to complete the process.
       

Sections and Columns

  • Name Definition
    Instances This displays all instances of the claim including resubmission/corrections.
    Notes This section displays any notes related to the claim, regardless of author.
    Workflow This section is used to work the claim.
    Issues This section indicates if there are any roadblocks in getting the claim paid.
     
    Payments This section displays any recorded payments applied to the claim.
    Processing Events This section displays the claim's electronic submission history, as well as the current payer status and/or rejections.
     
  • Name Definition
    Service(s) This is the name(s) of the service(s) on the claim.
    Service Date(s) This is the first DOS and last DOS on the claim.
    Charges This is the sum of charges on a claim.
    Covered This is the sum of the covered charges on a claim.
    Balance This is what is currently owed on a claim.
    Patient Responsibility This indicates how much of the covered amount is the patient responsibility. 
    Paid This is the amount the insurance company paid.
    Balance (Difference Covered vs Expected) This is the amount that was covered in comparison to what the expected rate is. 
    Patient Billable  This field will only be available to those with the Patient Billing module. 

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