Work Claims at the Patient Level

Claims can be worked at the patient level by navigating to the Patient > Treatment Episodes > Insurance Billing > Claims section of the RCM. Let's review how to work claims in this section together! 

User Permissions 

Admin-level user profiles can work claims without additional user permissions. Organization Users and Managing Organization Users will require Edit-level permissions under Insurance Claim Access in the user profile. For further reading on user types and permissions, click here. 

Section Overview

Let's break this section overview into three parts: Filters, Actions, and Definitions.

• 

  Name	Definition
  Claims	The filter instructs the system to locate claims based on their current disposition, including Open, Closed, or Voided.
  Date Type	Filter claims are based on the claim's first and last Dates of service.
  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
  Create Inst Legacy Claim	This feature is used to create manual Institutional claims to account for payments received in the RCM for claims that were submitted outside the RCM.
  Create Prof Legacy Claim	This feature is used to create manual Professional claims to account for payments received in the RCM for claims submitted outside the RCM.
  Bulk Update Workflow/Notes/Issues	This feature is used to update the Claim Queue, Claim Status, Assigned User, Follow-Up Date, Notes, Issues, and Claim State of one or more claims simultaneously.
  State	This indicates whether the claim is open, closed, or voided.
  Status	This provides additional information about the claim's current stage.
  Queue	This is the queue the claim is currently assigned to for follow-up.
  Follow-Up	This is the next scheduled 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 PoTF: Generates a pdf copy of the Proof of Timely Filing Resubmit: Allows a user to resubmit a claim without generating corrections

• 

  Name	Definition
  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.
  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.

Workflow

Let's review how to work claims from within the patient's profile! 

• 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.