Reviewing electronic billing claim details

The claim details screen contains several sections that allow you to view detailed information about the claim and the service lines included on it.

Claim summary

The information displayed in the claim summary will vary based on whether the claim type is professional or institutional.

Professional claim summary

In the Summary section of professional claims, you will see the Client name (click the hyperlink to open the client profile), Service date range, and place of service. If a Delay code or Comment have been added to the claim, or if an Internal control number was received for the claim, these details will also appear in the summary.

To add a delay code or make any other changes to the claim summary, click the  icon. Note that you can only edit a claim when it is open.

In the Edit claim summary dialogue, you can adjust the Place of service, select a Delay code, or add a Comment. The Internal control # field will only be available to complete once an 835 EDI file has been received for the claim (must be in a status of paid or denied).

When you have finished making changes, click Save.

Institutional claim summary

In the summary section of institutional claims, you will see the Client name (click the hyperlink to open client profile), Service date range, Type of bill, Priority (type of admission), Point of origin for admission or visit, Patient discharge status, and any Value codes that have been added for the electronic billing payor or the claim. 

To add a delay code, value code, or make any other changes to the claim summary, click the  icon. Note that you can only edit a claim when it is open.

In the Edit claim summary dialogue, you can adjust the fields in the Type of bill section: Facility code, Frequency code, Priority (type) of admission, Point of origin for admission or visit, and Patient discharge status. You can also select a Delay code or enter a Comment.

To add a value code to the claim, select the +Add value code button. 

In the Code field, start typing to select one of the predefined codes. Enter the Amount and then click Save. You can add up to 12 value codes to a claim. 

When you have finished making changes to the claim summary, click Save.

⚠️ You can also directly manage authorization and member numbers at the claim level, and view those within the claim summary card. You can view and edit member numbers associated to a selected claim without having to re-do the authorization, visit approval, and claim generation processes. If that member number exceeds 50 characters, or if the user attempts to send a claim without a member number, the system will display an error message and you must fix it before continuing. Clients whose claims require both the authorization and member numbers will see the error message if any one of the numbers is missing.

Balance card

The balance card on the claim details screen contains information about the total amounts being billed and currently due for the claim.

Total billed represents the total amount of the sales transaction. It will also reflect any changes made to account for banked time or credit or debit notes that have been added. 

Note that the bank adjustment and subtotal amounts will not appear until after the claim is sent as bank calculations are made at the same time that the sales transactions are created.

Amount due represents the current amount owed toward the claim by the funder after any payments or adjustments have been applied.  Any payments or adjustments for the claim will appear beneath the Amount due.

Service lines

Each service line on a claim represents a single visit for the client and funder and a single transaction in the subledger. In the service lines section of the claim details page for professional and institutional claims, you will see two tabs: Claim and Accounting.

The Claim tab contains claim-level information about the details that will be sent on the claim.

 For each visit on a professional claim, you will see the Visit ID (click the hyperlink to open the visit dialogue), Visit start date and time, Procedure code, Procedure modifier, Approved time, Approved units, Units adjustment, and Units sent.

For institutional claims, you will also see the Revenue code and the Revenue code description.

If the service line contains more than one visit, a Multiple visits button will be displayed in the visits column. Click the button to view the visit IDs.

In the Visits breakdown dialogue, you will see the visit ID for each visit included on the service line. Click the hyperlink to open the visit dialogue for each visit.

Approved units represent the number of billing increments approved for the visit. The Unit adjustment field displays the number of billing increments from the time bank that were used to round the visit units up or down to the nearest whole unit. Units sent represents the total number of billing increments (in whole units) that will be billed for the visit on the claim.

Select View history to review any changes that have been made to the service line.

From the Service line history, you will be able to see the date and time at which each update was made and the Bill code, amount Billed, and Units sent at the time of each change.

On institutional claims, you will also see the Revenue code and Revenue code description for the service line:

To review the transaction details for each service line, switch to the Accounting tab.

In this grid, you will see information about the transactions that will be logged for each visit on the claim. For each visit, you will see the Visit ID, Visit start date and time, Bill code, Approved time, Adjusted time, amount Billed, amount Paid, amount of any Adjustments, and the total Balance owed. The adjusted time represents any adjustments to the approved time that were made in order to round the units sent up or down to the nearest whole unit.

You can select Transactions to review the transaction history for a service line. 

If multiple visits are included in the service line, Multiple visits will be displayed in the Visits column. Click the button to view the visit IDs.

No transactions will be available to review until after a claim is sent and the sales transactions are created. Once a claim has been sent, however, you will be able to see the sales transaction created for the service line and any credits or debits to the bank.

You can also add transactions from this screen to open claims in rejected, paid, or denied status.

Claim events

The Claim events section logs the changes to the claim as it moves through different statuses. It will display the Date and time of the update, the Event that resulted in the update (such as a change in status, edit made to the claim, or transaction added), Status at the time of the update,  the user who the made the changes (Changes made by), whether it was Resubmitted, the total number of Units sent for the claim, Internal control # (if applicable), Balance, total Billed, amount Paid, Adjusted amount, claim Balance, and Delay code (if applicable).

The Issues column will be left blank unless an error occurs when sending the 837 that prevents the claim from moving forward in the billing process.