Work Claims at the Claim Level

Claims can be worked on at the claim level by clicking the Claim ID hyperlink within the Work Center > Insurance Claims > Work Claims section or within Patient > Treatment Episodes > Insurance Billing > Claims section of the RCM.

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

This section of the RCM has two tabs where claims can be worked on: Work Claim and Instances. The Work Claim tab is used to make notes and updates to a claim, track payments, and track processing events. The Instances tab is used to view more granular details about each version of the claim, the line items, and EDI information.

Work Claim

The Work Claim tab has four quick links and five subtabs that assist a user in working the claim at an individual level.

1. The Patient name quick-link will redirect the user to the Patient > Treatment Episode > Intake > Admit/Discharge section of the patient's profile.
2. The View Eligibility quick link generates a window displaying the patient's eligibility status from the most recent eligibility check.
3. The Claim Instance quick link will redirect the user to the Claim Details section of the most recent iteration of the claim.
4. The Show Details quick link generates a window that displays information like the Claim State, Submission Status, and Submission Method.
This section displays any notes related to the claim, regardless of the author.
This section is used to work on the claim. In this section, users can update the QSI, assign a user, itemize the claim, close the claim, or force the claim to paper.
This section indicates if there are any roadblocks in getting the claim paid.
The Payments subtab displays a record of each payment associated with the claim.
The Processing Events provide a log of communication between the clearinghouse and the payer. These events indicate whether a claim was submitted correctly the first time or if the claim was rejected and requires additional modifications.

Instances

The Instances tab provides the claim's history and granular details of the claim when the Control Number is clicked.

The Control Number is the claim number assigned by the RCM and provides granular details.
The Status indicates whether the claim has been created, submitted, or marked as submitted.
The Submitted column displays the day the claim was printed, submitted, or marked as submitted.
The Sequence indicates whether the claim was submitted to the primary payer, secondary, or tertiary payer.
The Version indicates which variation of the claim control number is associated with.
The State reflects whether the claim is still open and being worked on or if it has been closed.
The Type and Method columns indicate the claim form type and whether the claim was submitted electronically or on paper.
The Payer Name and Payer Status columns indicate whether the claim is pending, rejected, or accepted by the payer to which the claim was submitted.
The ICN is the claim number assigned by the payer.
The Charges column reflects the sum of all charges submitted in the claim.

Claim Details

The details section of a claim provides a granular view of the information that comprises the claim.

The Details subtab displays the same information as the Instances tab and includes the Authorization number when applicable.
The Form Contents subtab provides the most accurate details of a claim. The information displayed here details the contents of the EDI file.
The Line Items subtab displays a line item for each DOS on the claim and includes information such as the service name, procedure code, and charges.
This section displays a record of each document, if any, that the claim was submitted with.
The Claim Form PDF provides a visual of the claim form that was generated and submitted to the payer by the clearinghouse.