CHAPTER

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7Creating Claims

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Learning Outcomes

When you finish this chapter, you will be able to:7.1 Describe the role of claims in the billing process.

7.2 Discuss the information contained in the Claim Management dialog box.

7.3 Demonstrate how to create claims in Medisoft.

7.4 Describe how to locate a claim that has already been submitted.

7.5 Discuss how claims are edited in Medisoft.

7.6 Explain how to change the status of a claim.

7-2

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Learning Outcomes (Continued)

When you finish this chapter, you will be able to:7.7 List the steps required to submit electronic claims

in Medisoft.

7.8 Describe how to add attachments to electronic claims.

7-3

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Key Terms

• filter• navigator buttons

7-4

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7.1 The Role of Claims in theBilling Process

7-5

• Once the services a patient has received from a provider have been entered into the PMP, the next step is to create insurance claims– Most important document for correct reimbursement– Communicate information about a patient’s diagnosis

and procedures and the charges to a payer

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7.1 The Role of Claims in theBilling Process (Continued)

7-6

• The HIPAA standard transaction for electronic claims is the HIPAA X12 837 Health Care Claim or Equivalent Encounter Information (837P).

• The paper format is known as the CMS-1500 claim form.

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7.2 Claim Management in Medisoft 7-7

• Claims are created in the Claim Management area of Medisoft

Claim Managementdialog box

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7.2 Claim Management in Medisoft(Continued)

7-8

• The upper-right hand corner of the Claim Management dialog box contains five navigator buttons

• Navigator buttons simplify the task of moving from one entry to another

Navigator buttons

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7.3 Creating Claims 7-9

• The Create Claims button in the Claim Management dialog box opens the Create Claims dialog box

Create Claimsdialog box

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7.3 Creating Claims (Continued) 7-10

• A filter is a condition that data must meet to be selected

• The Create Claims dialog box uses these filters:▪ Transaction dates ▪ Location

▪ Chart numbers ▪ Assigned

▪ Primary insurance ▪ Attending

▪ Billing codes ▪ Enter Amount

▪ Case indicator

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7.3 Creating Claims (Continued) 7-11

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

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7.4 Locating Claims 7-12

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

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7.4 Locating Claims (Continued) 7-13

• The List Only Claims That Match dialog box

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7.5 Editing Claims 7-14

• To edit a claim, first select it in the Claim Management dialog box, then click the Edit button to display the Claim dialog box

Edit button

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7.5 Editing Claims (Continued) 7-15

• Information can be edited on the five tabs of the Claim dialog box

Five tabs

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7.6 Changing the Status of a Claim 7-16

• When claims are transmitted electronically, the Claim Status for each claim automatically changes from Ready To Send to Sent– Claim statuses can be changed manually in the

Change Claim Status/Billing Method dialog box

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7.7 Submitting Electronic Claims 7-17

• To submit electronic claims in Medisoft– Select Revenue Management from the Activities

Menu– The Revenue Management window opens

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7.7 Submitting Electronic Claims (Continued)

7-18

• Select Claims on the Process menu of the Revenue Management window– A list of claims ready to be sent is displayed– Click Check Claims and the EDI receiver to perform

an edit on the claims– The Send button is used to submit the claims

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7.8 Sending Electronic ClaimAttachments

7-19

• The EDI Report area within the Diagnosis tab of the Case dialog box indicates when an attachment will accompany the claim and how the attachment will be transmitted

• The EDI Report area contains three boxes:– Report Type Code– Report Transmission Code– Attachment Control Number

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7.8 Sending Electronic ClaimAttachments (Continued)

7-20

• The EDI Report area informs the payer of the presence and status of any attachments

EDI report area