Working Claims

The Work Claims tab in the Work Center > Insurance Claims is designed to help organize your claim management workflow and automatically sorts claims by follow-up date. From the Work Center, clicking on the Claim ID or patient name will bring you to a screen where follow-up details can be updated. Any details updated on the patient's Claims tab will automatically be reflected in the Work Center.

Tab Layout

The Work Claims tab shows all claims grouped by payer in an expand/collapse view. Click on the section header to expand or collapse the selection. Use the Select All/Select None options within the sections to select or deselect the claims in that payer section.

Here there are many different filters and options to assist you in the claims follow-up process. 

• Practice: If there are multiple Practices in the system use this drop-down menu to select which one you’d like to see claims for. If you want to display all practices, select (ALL). 
• Claim: This filter has three options: Open, Assigned to Me; Open, All; and Open, Unassigned.  Only claims assigned to you will show up under the first option.  All claims both assigned and unassigned will show up under the second option. The third option will not show any assigned claims only ones that do not have an assigned user. 
• Group By: The Group By filter will add subtotals to each group for the number of claims, patients, and charges. This filter has six options: HCPCS/CPT, Organization, Payer, Queue, Service, and Status.
  • HCPCS/CPT code will group claims by their procedure codes.
  • Organization will group claims by the managing organization so if Facility X and Facility Y are both managed by Organization A, the claims for Facility X and Facility Y will be grouped under Organization A. Organizations will be sorted alphabetically.
  • Grouping by Payer will group claims depending on who the payer is. Payers will be sorted alphabetically.
  • Grouping by Queue only applies if you wish to look at multiple queue at one time. This will show claims grouped by the queue they are currently in. 
  • When grouping by Service, if there are multiple services on one claim, the claim will only appear one time under the first service listed.
  • Selecting Status will group claims by their current status.
• Sort By: This filter has eight options: Patient, Follow-Up Date, Queue, Assigned To, HCPCS/CPT, Service, Days Outstanding, and Last Action Date. Within the Group By setting you have selected, this feature sorts claims by one of these eight options. 
  • Patient will sort by patients alphabetically. 
  • Follow-Up Date will show the earliest follow-up date first. 
  • Queue will sort by queue alphabetically. 
  • Assigned To will sort by claim assignments alphabetically. 
  • HCPCS/CPT will sort by procedure code within each group. 
  • Service will sort claims by the first service listed. If there are multiple services, only the first will be used to sort. 
  • Days Outstanding will show claims with the greatest number of days since submission first. 
  • Last Action Date will show claims with the most recent action date first.
• Queue: This filter comes standard with a Payer, Review, and Resubmit but can be customized in the Managing Organization Admin. Selecting a queue from this menu means that only claims from that queue will be displayed. If you wish to display all queues at one time, select (All).
  • The Payer queue shows claims that are pending a follow-up with the insurance company.
  • The Review queue is where claims are sent when EOBs are received and the follow-up date is set for the next business day. 
• Assigned To: Displays all the users in the system. Selecting a user here will only show claims assigned to that person. This filter is only available when Claims: Open, All is selected. 
• Follow-Up: This is programmed to automatically be set for today's date. All claims with follow-ups on that date and before will be displayed. 

Claim Follow-Up by Patient

Clicking on the patient's name will navigate you to their Claims tab, where you can view additional information about the claim and make updates to key information like state, queue, and status.

Filters

The Claims tab contains the following filters:

• Claims: This filter has six options: All, Closed, Discontinued, Open, Unpaid, and Voided.
• Sort By: This drop-down has nine options: Assigned To, Charges, Claim ID, Claim Status, Days Out, DOS, Follow-Up Date, Queue, and State. Use these criteria to select which claims you want to appear first. 

Tip: Most of the time it makes sense to sort by follow-up date. This shows claims with the oldest follow-up date first. If there are multiple claims with the same follow-up date they will be arranged by date of service (DOS). Record call notes for each claim. It is best to do this in a separate document then transfer notes into AveaOffice. Each person has a different way of sorting their notes, find which way works best for you. Notes should all follow the same format. 

Claim State

Claims will remain in an Open state and remain on A/R Reports until the state is manually changed from Open to Closed. From the Work Claims tab, claims can be closed individually or as part of the Bulk Update function.

Claim Queue

The Queue corresponds to the list in the Work Center that the claim is assigned to. The idea here is that claims in the Payer queue need to be followed up with the payer, claims in the Review queue have payments that were recently posted that need to be reviewed, and claims in other queues are designated by the place that claims need follow up on.

You'll find Payer, Review, and Resubmit queues configured as defaults in your Managing Organization. 

• Payer: When a claim is submitted or resubmitted, it is automatically sent to the Payer queue along with a follow-up date and claim status.
• Review: Claims go into the Review queue when a manual payment is posted or when an ERA matches to a claim.
• Resubmit: The Resubmit queue has claims that are rejected by the clearinghouse or payer upon the first submission.

Click here for instructions on creating custom Queues.

Claim Status

This area helps briefly articulate the claim's current lifecycle stage. You will manually change the status as you work the claim. 

You will also see a list of default statuses to get an idea of what can be used. These statuses can be customized at any time by your Managing Organization Admin.

• Appeal - Needed, Not Written: The claim has reached the appeal process but the appeal has not yet been written.
• Appeal - Sent - Pending Payer Registration: The appeal has been written and sent. We are waiting for the payer’s response.
• Billing - EOB Not Received: The billing team has not received the EOB yet.
• Billing - Pending Manager Review: The claim is pending review by a manager.
• Billing - Resubmit Needed: The claim requires changes and resubmission.
• Closed – Paid: The claim has been paid. Usually, a claim with this status needs to have it's State updated Closed.
• Closed - Paid - OOP Maximum Met: The patient has met their out-of-pocket maximum and the insurance has paid as much as it will on the claim.
• Payer - Original Claim Processing: When a claim is first submitted, during the first 30 days, it will have this status, unless manually changed.
• Payer - Re-submitted - Waiting on EOB: If a claim is resubmitted, it will have this status.
• Payer - Secondary Claim Processing: If a secondary claim has been sent out, this status can be used to differentiate primary claims from secondary claims. This tag can be especially helpful when looking at days outstanding on the AR Report.
• Research - Claim Paid Incorrectly: If a claim is paid incorrectly, we may need to complete research with the payer or internally to figure out why.
• Research - Issue Not Clear: If a payer representative cannot provide complete information, we might have to research the issue elsewhere. 

Follow-Up Date

The Follow-Up Date for the claim is what determines when the claim appears in the Organization Dashboard and in the Work Center. The Work Center will default to showing you claims that have follow-up dates for today and prior to today. You won't see claims in this list with follow-up dates in the future until that day comes. 

Assigned To

A great way to quickly see which users are working on which claims is to use the Assigned To field. On a larger team, you will know exactly who to contact if there are questions about a patient or claim status. Claims can be assigned from the patient's claims page by changing the Assigned To field. 

Notes

Adding notes to claims that specify processing, payment, and claim status details has always been a great way to keep track of the history of the claim. This is a great place to add a call reference number or specific instructions for a resubmission. 

Issues

If there is delayed processing on a claim, the best practice is to add an issue to the claim. This will be most beneficial when running A/R Reports, so you'll be able to easily digest why claims have delayed processing. 

Expand Details

Allows users to see additional information on a claim level including provider, authorization, payment, and patient responsibility breakdowns. 

Bulk Updates

From the Work Center, claims can be updated in bulk to change the Queue, Status, Follow-Up Date, add Notes, Assign a User, and update the State.

1. Select all to choose all displayed claims. Clicking Select None will un-check all claims. 
2. Click the Bulk Update Workflow/Notes button.
3. From the Bulk Update window, use the drop-downs to select the desired updates.

   • Claim Status: Describes where the claim is in its lifecycle. Claim status is very important for reporting as reports can be sorted by claim status. Claim Status provides a snapshot of what is going on with the claim without delving into the notes. For example, a status of Payer-Original Claim Processing means that the claim has not yet processed or denied, it is either in process or has not yet been followed up. Statuses should be updated whenever a situation changes with a claim. 

   • Assigned User: Who is responsible for the next follow-up, can be left unassigned. 

   • Follow-Up Date: When the next follow-up should be made. When that date is reached, the claim will show back up in the queue. 

   • Add Note: Put call notes with correct formatting here. 

4. Bulk updating the claim State to Closed will create a patient billable for continuing the patient collections process in AveaOffice Patient Billing. 
5. Important: Bulk updating the claim State to Closed will not create a secondary claim for submission to the secondary payer. You will need to close those claims manually in order to continue the billing process.

Download

To download the Work Claims tab, choose Download as Excel File.