Claims

A Claim is a request for a payer to pay a provider for procedures performed. A claim is created after an encounter has the procedures created. In the image at the right is the upper left corner of an encounter dialog. You can see here that "Alice Patient" had an encounter on 4/18/2003 and had three procedures performed. (GD101, G0001, 93000) When all procedures have been recorded, it's time to file a claim. Selecting the New button next to the Claims label in the Encounter dialog does this. Selecting this button will cause the Claim Edit dialog to appear. (Shown below)

Claim Edit Dialog

The Claim Edit dialog contains information that is for reference only and fields for entering information about the claim. Each section of this dialog is explained below.

Claim - Encounter Information

Across the top of the Claim Edit dialog is a gray region with Encounter information displayed. This information is not editable here and is displayed for reference only. The three items that uniquely define an encounter are displayed. In the example above, patient Alice E. Patient had an encounter with Mary A. Provider on April 18, 2003.

Edit Claim

1. Date - claims are made some time after an encounter depending on how your office operates. Usually a Claim is filed within a day or two of the encounter. So, this date is the date when the Claim is made.
2. Payer Billed - identifies which of the payers will be sent the claim. This is a popup that contain a list of the possible payers for the patient. The list is compiled from the Coverages that have been created for a patient. As a payer is selected from the list, the associated guarantor for that coverage is listed below the popup.
3. Level - defines the level of coverage that the selected Payer Billed provides for the patient. There are three choices, Primary, Secondary and Tertiary. This is a non-editable field that automatically gets filed in when a Payer Billed is selected.

Other editable information that can optionally be defined for the claim include:

• Biller - is a popup list of billers that identifies the person in your office that filed the claim. The choices available in the popup field are compiled from the list of possible billers that were Configured for your practice.
• Claim Status - defines the current state of this claim
• Not Selected - the default status
• Normal
• Resubmitted Corrected
• Corrected/POTA
• Previously Rejected
• No Payment Received
• Denied
• Medicare Status - a code indicating the patient's Medicare status
• Other Insurance - a code indicating that the patient has other health insurance.
• Assignment or Participation Code - a code identifying the assignment/participation status of the provider
• Miscellaneous Date - a date associated with the service being billed.
• Prior Authorization # - a number assigned to a payer to indicated that prior authorization was received on a claim.
• Primary Payer - a code to indicate the primary payer on a secondary payer claim.
• Type Indicator - code indicating the non-finalized processing status.
• Claim Number - a unique number, assigned by the biller, to each claim within the file.
• Delayed Reason - free form text

Claim - Dialog Buttons

TFM provides four control buttons for this dialog:

• Cancel - don't record that current changes and close the dialog.
• HCFA - create a HCFA 1500 form for this claim. (see next chapter)
• Submit - add this claim to the EDI list of claims. (see following chapter)
• Save - record all of the claim data and close the dialog.