1. 10
Claim Management

2. Learning Outcomes When you finish this chapter, you will be able to:
10-2
When you finish this chapter, you will be able to:
10.1 Briefly compare the CMS-1500 paper claim and the 837 electronic claim.
10.2 Discuss the information contained in the Claim Management dialog box.
10.3 Explain the process of creating claims.
10.4 Describe how to locate a specific claim.
10.5 Discuss the purpose of reviewing and editing claims.
10.6 Analyze the methods used to submit electronic claims.

3. Learning Outcomes (Continued)
10-3
When you finish this chapter, you will be able to:
10.7 List the steps required to submit electronic claims.
10.8 Describe how to add attachments to electronic claims.
10.9 Explain the claim determination process used by health plans.
10.10 Discuss the use of the PM/EHR to monitor claims.

4. Key Terms 10-4 adjudication aging claim status category codes
claim status codes
claim turnaround time
CMS-1500 (08/05) claim
companion guide
crossover claim
data elements
determination
development
filter
HIPAA X Health Care Claim
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response
insurance aging report
medical necessity denial
National Uniform Claim Committee (NUCC)
navigator buttons
Teaching Notes: There are a lot of key terms, but many of them might already be familiar to your students. Give a pop quiz of the terms to see how many students know. Grade the quiz in class and use results to focus your lecture on terms that most or all students missed.

5. Key Terms (Continued) 10-5 pending prompt payment laws suspended
timely filing
Teaching Notes: See notes on Slide 5.

6. 10.1 Introduction to Health Care Claims
10-6
Timely filing—health plan’s rules specifying the number of days after the date of service that the practice has to file the claim
HIPAA X Health Care Claim—HIPAA standard format for electronic transmission of the claim to a health plan
CMS-1500 (08/05) claim—mandated paper insurance claim form
National Uniform Claim Committee (NUCC)—organization responsible for claim content
Learning Outcome: 10.1 Briefly compare the CMS-1500 paper claim and the 837 electronic claim.
Teaching Notes: Provide sample completed insurance claim forms that contain errors and have student groups pinpont the errors. Discuss as a class and reinforce the fact that clean claims are critical to proper reimbursement.
Ask students why they think that, in the era of electronic records, the CMS-1500 is a mandated paper form.

7. 10.1 Introduction to Health Care Claims (Continued)
10-7
Data element—smallest unit of information in a HIPAA transaction
Notable features of the HIPAA 837 transaction (as compared to the CMS-1500 paper form):
It has many more data elements, though many are conditional and apply to particular specialties only.
It uses some different terms, and a few additional information items must be relayed to the payer.
It requires a claim filing indicator code.
Learning Outcome: 10.1 compare the CMS-1500 paper claim and the 837 electronic claim.
Teaching Notes: When discussing the differences between HIPAA 837 and the CMS-1500, cite what some of the “many more data elements” are and why they are required.

8. 10.2 Claim Management in Medisoft Network Professional
10-8
Insurance claims are created, edited, and submitted for payment within the Claim Management area of MNP.
Information contained in the Claim Management dialog box:
All claims that have already been created
Status of existing claims
Options for editing, creating, printing/sending, reprinting, and deleting claims
Navigator buttons—buttons that simplify the task of moving from one entry to another
Learning Outcome: 10.2 Discuss the information contained in the Claim Management dialog box.
Teaching Notes: Show Figure 10.5 in the textbook, the Claim Management dialog box, and ask students to look over it and provide feedback. What do they notice? How is it organized? Is it intuitive?
Explain that there are FIVE navigator buttons, and direct students’ attention to Figure 10.6 in the text for a visual connection.

9. 10.3 Creating Claims
10-9
Claims are created in the Create Claims dialog box of MNP; to create a claim:
Click the Create Claims button in the Claim Management dialog box; the Create Claims dialog box will open.
Apply the appropriate filters; any box that is not filled in will default to include all data.
Click the Create button to create the claims.
Filter—condition that data must meet to be selected
Learning Outcome: 10.3 Explain the process of creating claims.
Teaching Notes: When discussing filters, provide concrete examples of what a filter might be. Discuss filtering by transaction dates, billing codes, location, etc.
Ask students to discuss the advantages and disadvantages of using filtering.
Have students complete Exercise 10.1.

10. 10.4 Locating Claims To locate a claim in MNP: 10-10
Click the List Only… button in the Claim Management dialog box; the List Only Claims That Match dialog box will be displayed.
Apply the appropriate filters.
Click the Apply button.
The Claim Management dialog box is displayed, listing only the claims that match the criteria that were selected.
Claims can now be edited, printed, or transmitted from the Claim Management dialog box.
Learning Outcome: 10.4 Describe how to locate a specific claim.
Teaching Notes: Ask students to brainstorm some possible reasons why a claim may need to be relocated (It might need to be checked for accuracy; it might need to be reviewed before resubmission if it has been rejected previously; etc.)
Note again that you can apply various filters to make it easier to search for a claim: chart number, insurance carrier, etc.
Have students complete Exercise 10.2.

11. 10.5 Reviewing Claims Claims should be checked before transmission.
10-11
Claims should be checked before transmission.
Most PM/EHRs provide a way for billing specialists to review claims for accuracy.
In MNP, this task is accomplished by using the Edit button in the Claim Management dialog box to load the Claim dialog box.
The more problems that can be spotted and solved before claims are sent to carriers, the sooner the practice will receive payment.
Learning Outcome: 10.5 Discuss the purpose of reviewing and editing claims.
Teaching Notes: It is important to note for students that, when reviewing a claim in MNP, the baseline information (date of creation, chart number, claim number, patient name, case number) CANNOT be edited, only the information contained in the tabbed sections – carriers, transactions, comments.
Have students complete Exercise 10.3.

12. 10.6 Methods of Claim Submission
10-12
Three most common methods of transmitting electronic claims:
Direct transmission to the payer—Claims created in the PM/EHR are sent to the payer’s computer directly via a connection.
Direct data entry—A member of the provider’s staff manually enters claims into an application on the payer’s website.
Transmission through a clearinghouse—Practices send their claims to clearinghouses to be edited and then sent to the payer; this is the method used by most providers.
Learning Outcome: 10.6 Analyze the methods used to submit electronic claims.
Teaching Notes: Have students debate the merits and drawbacks of the three methods of claim transmission. Which one do they think is best? Why? Which would they most like to employ in their future jobs? Why?

13. 10.6 Methods of Claim Submission (Continued)
10-13
Companion guide—guide published by a payer that lists its own set of claim edits and formatting conventions
Crossover claim—claim billed to Medicare and then submitted to Medicaid
Learning Outcome: 10.6 Analyze the methods used to submit electronic claims.
Teaching Notes: Discuss with students why each payer seems to have their own ways of dealing with claim edits and formatting. If everyone did things the same way, there would be no need for a companion guide; why is there so much inconsistency?
Remind students that Medicaid is known as the “payer of last resort.”

14. 10.7 Submitting Claims in Medisoft Network Professional
10-14
To submit electronic claims in MNP:
Select Revenue Management > Revenue Management… on the Activities menu; the Revenue Management window opens.
Select Claims on the Process menu.
Select an EDI receiver.
To perform an edit check, click Check Claims; when complete, the Edit Status column displays the status of each claim.
To continue with ready-to-send claims, select Send, select Claims, and select the EDI receiver.
Learning Outcome: 10.7 List the steps required to submit electronic claims.
Teaching Notes: Explain to students that MNP has a number of built-in edit functions, such as ANSI, common, and user-defined edits. More options, like the CCI edits and Medicare policy edits, are available but require an annual subscription. Ask students if the annual fee is worth it to have those additional editing capabilities – why or why not?
When walking through the steps to submit electronic claims, use the screenshots in the textbook to provide a visual for students (pages ).

15. 10.7 Submitting Claims in Medisoft Network Professional (Continued)
10-15
To submit electronic claims in MNP (continued):
A claim file is created and a preview report is displayed.
If any errors are identified, the claims must be edited before they can be transmitted.
Click the Send button to send the claim files.
Learning Outcome: 10.7 List the steps required to submit electronic claims.
Teaching Notes: See notes on Slide 14.

16. 10.8 Sending Electronic Claim Attachments
10-16
Attachments that accompany electronically transmitted claims must be referred to in the claim.
In MNP, the EDI Report Area within the Diagnosis tab of the Case dialog box is used to indicate that there is an attachment and how it will be transmitted.
An attachment control number is required if the transmission code is anything other than AA.
Learning Outcome: 10.8 Describe how to add attachments to electronic claims.
Teaching Notes: Ask students why any attachments must be referenced in the claim itself.
Give a pop quiz of the report type codes to reinforce them with students.

17. 10.9 Claim Adjudication
10-17
Adjudication—series of steps that determine whether a claim should be paid
Initial processing—Data elements are checked by the payer’s front-end claims processing systems.
Automated review—Payers’ computer systems apply edits that reflect their payment policies.
Manual review—Claims with problems are set aside for further review.
Determination—Payer makes a decision about how to handle a claim.
Payment—If due, payment is sent to the provider.
Learning Outcome: 10.9 Explain the claim determination process used by health plans.
Teaching Notes: Discuss why there are so many steps taken before determination of claim payment.
Explain that in the Automated Review step alone, there are TEN different facets that are evaluated (found on textbook pages ).

18. 10.9 Claim Adjudication (Continued)
10-18
Suspended—claim status when the payer is developing the claim
Development—process of gathering information to adjudicate a claim
Determination—payer’s decision about the benefits due for a claim
Medical necessity denial—refusal by a plan to pay for a procedure that does not meet its medical necessity criteria
Learning Outcome: 10.9 Explain the claim determination process used by health plans.
Teaching Notes: See notes on Slide 17. Also provide examples of various claims and ask student groups to determine what status their assigned claim might have been given and why. Choose a variety of claims; if no actual sample claims are available, create some scenarios that involve each of the key terms listed here.

19. 10.10 Monitoring Claim Status
10-19
Practices closely track their accounts receivable using their PM/EHR.
After claims have been accepted for processing by payers, their status is monitored using the PM/EHR.
Monitoring claims during adjudication requires two types of information:
The amount of time the payer is allowed to take to respond to the claim
How long the claim has been in process
Learning Outcome: Discuss the use of the PM/EHR to monitor claims.
Teaching Notes: Note that a practice IS allowed to send an electronic inquiry at any time to a payer. Direct students’ attention to Table 10.2 in their text, which outlines some Claim Status Codes that a practice might receive in reference to a query.
Ask students what time frame they think might be fair for claim payment/turnaround. Compare their responses to actual wait times and use that as entry into a discussion on why payments tend to take a long period of time.

20. 10.10 Monitoring Claim Status (Continued)
10-20
Prompt payment laws—state laws that mandate a time period within which clean claims must be paid
Claim turnaround time—time period in which a health plan must process a claim
Aging—classification of accounts receivable by length of time
Insurance aging report—report that lists how long a payer has taken to respond to insurance claims
Learning Outcome: Discuss the use of the PM/EHR to monitor claims.
Teaching Notes: Most of the key terms on this slide and the following slide might have already been covered at the beginning of this PowerPoint. If so, refresh students’ memories and tie the terms into the section being discussed. If not, use this time to showcase and explain the terms using examples to strengthen understanding.
Give students an assignment to research prompt payment laws – are they the same in every state? Are they similar? Are there any unique variations? Why do students think this is the case?

21. 10.10 Monitoring Claim Status (Continued)
10-21
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response—electronic format used to ask payers about claims
Claim status category codes—used to report the status group for a claim
Pending—claim status in which the payer is waiting for information before making a payment decision
Claim status codes—used to provide a detailed answer to a claim status inquiry
Learning Outcome: Discuss the use of the PM/EHR to monitor claims.
Teaching Notes: See notes on Slide 20.
When discussing claim status codes, call out various codes and ask students what response they think a practice would have upon receiving that code.