Overview

As a Biller, you are responsible for creating and submitting medical claims, managing patient information, and tracking claim status throughout the billing cycle. This guide will help you efficiently perform your daily billing tasks.

Key Responsibilities

• Create new claims for medical services
• Submit claims to clearinghouse and payers
• Manage patient demographics and insurance information
• Track claim status and respond to rejections
• Handle denials and resubmissions
• Maintain accurate billing records

Managing Patients

Adding a New Patient

Searching for Patients

Use the patient search feature to quickly find existing patients:

• By Name: Type patient's first or last name
• By Date of Birth: Filter by DOB
• By Member ID: Search using insurance member ID

Updating Insurance Information

1. Select the patient from the patient list
2. Click Edit Insurance
3. Update insurance details as needed
4. Save changes before creating new claims

Verifying Eligibility

Before submitting claims, verify patient eligibility:

1. Open patient record
2. Click Check Eligibility button
3. Review eligibility response for:
   • Active coverage status
   • Copay and deductible information
   • Coverage limitations
   • Prior authorization requirements

Creating Claims

Step-by-Step Claim Creation

Required Fields

The following fields must be completed before submitting a claim:

• Patient Information: Name, DOB, Address, Sex
• Insurance Information: Payer, Member ID, Relationship to Subscriber
• Provider Information: Rendering Provider NPI, Billing Provider
• Service Information: Service Date, Place of Service
• Clinical Information: At least one diagnosis code
• Charges: At least one service line with CPT code and charge amount

Common Field Mappings

Understanding CMS-1500 form fields:

• Box 1: Type of insurance (Medicare, Medicaid, Commercial, etc.)
• Box 6: Patient relationship to insured (Self = 18)
• Box 11: Insured's policy/group number
• Box 21: Diagnosis codes (ICD-10)
• Box 24A: Service dates
• Box 24B: Place of service code
• Box 24D: CPT/HCPCS procedure codes
• Box 24E: Diagnosis pointers
• Box 24F: Charges

Submitting Claims

Running Claim Audit

Before submitting, run the built-in audit tool to catch errors:

1. Open claim in Work in Progress status
2. Click Run Audit button
3. Review audit results:
   • Pass: Claim ready for submission
   • Warning: Review recommended (can still submit)
   • Error: Must fix before submission
4. Fix any errors identified
5. Re-run audit until all errors cleared

Single Claim Submission

1. Ensure claim passed audit
2. Click Submit Claim button
3. Confirm submission in dialog
4. System submits to clearinghouse
5. Status changes to "Submitted"
6. Claim number generated

Batch Submission

Submit multiple claims at once for efficiency:

1. Navigate to Claims Overview
2. Filter for "Audit Passed" status
3. Select multiple claims using checkboxes
4. Click Batch Submit
5. Review claims in batch
6. Confirm batch submission
7. Monitor submission progress

Validation Rules

The system enforces these validation rules:

• One claim per patient per date: Prevents duplicate submissions
• Valid NPI numbers: Provider NPIs must be 10 digits
• ICD-10 format: Diagnosis codes must be valid ICD-10
• CPT code validation: Procedure codes must exist in code set
• Date logic: Service dates cannot be in future

Tracking Claim Status

Claim Status Workflow

Claims progress through these statuses:

1. Draft: Newly created, not yet saved
2. Work in Progress: Saved but not ready for submission
3. Audit Passed: Validated and ready to submit
4. Audit Failed: Has validation errors, needs correction
5. Submitted: Sent to clearinghouse
6. Accepted: Clearinghouse accepted claim
7. Rejected: Clearinghouse rejected (technical errors)
8. Denied: Payer denied payment
9. Partial Payment: Claim partially paid
10. Paid: Claim fully paid

Viewing Claim Status

1. Navigate to Claims Overview
2. Claims grouped by status in tabs
3. Click tab to view claims in that status
4. Click individual claim for details

Handling Rejections

When a claim is rejected by the clearinghouse:

1. Navigate to Overview → Rejected tab
2. Click on rejected claim
3. Review rejection reasons/error codes
4. Common rejection reasons:
   • AAA: Invalid/missing data element
   • 16: Claim/service lacks information
   • 18: Duplicate claim/service
   • 26: Expenses incurred before coverage
5. Correct the errors
6. Resubmit claim (system creates corrected claim)

Handling Denials

When a claim is denied by the payer:

1. View denial in Overview → Denied tab
2. Review denial reason code (CARC)
3. Review remark code (RARC)
4. Common denial reasons:
   • Missing or invalid authorization
   • Service not covered under plan
   • Medical necessity not established
   • Timely filing limit exceeded
5. Determine if appeal is appropriate
6. If appealing, follow payer appeal process
7. If not appealing, adjust patient responsibility

Monitoring ERA (Electronic Remittance Advice)

Track payments and adjustments:

• Navigate to ERA tab
• View incoming payment files (835 files)
• System auto-posts payments to claims
• Review adjustments and reason codes
• Verify payment amounts match expected

Using Claim Templates

What Are Claim Templates?

Templates are pre-configured claim forms that speed up data entry for common scenarios. Use templates for:

• Routine office visits (99213, 99214, etc.)
• Common procedures (vaccinations, lab work)
• Standard service packages
• Frequently used diagnosis/procedure combinations

Creating a Template

1. Create a claim with desired settings
2. Fill in common fields (provider, place of service, etc.)
3. Add diagnosis codes and procedure codes
4. Click Save as Template
5. Enter template name and description
6. Select category (Office Visit, Surgery, Lab, etc.)
7. Add tags for easy searching
8. Click Save Template

Using a Template

1. Click Add Claim
2. Click Use Template button
3. Browse or search templates
4. Select desired template
5. Template populates claim form
6. Update patient-specific information
7. Update service date and charges as needed
8. Submit claim

Batch Processing

Batch Claim Actions

Process multiple claims simultaneously:

• Batch Audit: Run audit on multiple claims
• Batch Submit: Submit multiple claims to clearinghouse
• Batch Status Update: Change status of multiple claims
• Batch Export: Export multiple claims to file

Running Batch Operations

1. Navigate to desired claim view (e.g., Work in Progress)
2. Use filters to narrow claim list
3. Select claims using checkboxes:
   • Individual selection: Click each checkbox
   • Select all: Click header checkbox
   • Select range: Shift+Click
4. Click desired batch action button
5. Review batch summary
6. Confirm action
7. Monitor progress bar
8. Review results summary

Reports

Available Reports for Billers

• Claims Summary: Overview of all your claims by status
• Productivity Report: Number of claims created/submitted
• Rejection Report: Claims rejected with reasons
• Denial Report: Denied claims analysis
• Aging Report: Outstanding claims by age
• Payer Performance: Acceptance rates by payer

Running a Report

1. Navigate to Reports
2. Select report type
3. Set date range
4. Add filters (payer, provider, status, etc.)
5. Click Run Report
6. View results on screen
7. Export to Excel or PDF if needed

Scheduling Reports

Set up automatic report delivery:

1. Open desired report
2. Click Schedule
3. Set frequency (daily, weekly, monthly)
4. Enter email recipients
5. Select format (PDF or Excel)
6. Save schedule

Troubleshooting

Common Issues and Solutions

Cannot Submit Claim - Validation Errors

Problem: Submit button is disabled or errors appear

Solution:

• Run audit to identify specific errors
• Check all required fields are filled
• Verify diagnosis codes are valid ICD-10
• Verify procedure codes are valid CPT/HCPCS
• Check diagnosis pointers reference valid diagnosis positions

Claim Showing as Duplicate

Problem: Error message "Duplicate claim for this patient/date"

Solution:

• Check if claim already exists for patient on same service date
• If legitimate duplicate (e.g., multiple visits same day):
  • Use different place of service codes, or
  • Add modifier to distinguish visits
• If accidental duplicate, delete the new claim

Patient Insurance Not Loading

Problem: Insurance fields blank when selecting patient

Solution:

• Verify patient has insurance information entered in patient record
• Update patient insurance before creating claim
• Check insurance effective dates - may be terminated

Cannot Find Patient

Problem: Patient search returns no results

Solution:

• Try searching by different criteria (DOB instead of name)
• Check for spelling errors
• Verify patient exists in system - may need to add new patient
• Check if patient is marked inactive

Claim Stuck in "Work in Progress"

Problem: Saved claim not moving forward

Solution:

• Open claim from Claims Overview → WIP tab
• Complete all required fields
• Run audit to validate
• If audit passes, status will update to "Audit Passed"
• Then you can submit

Charges Not Calculating Correctly

Problem: Total charge is wrong

Solution:

• Verify units × charge = line total for each service line
• Check for extra decimal places or missing decimals
• Ensure charges entered as dollars and cents (e.g., 150.00, not 15000)

Best Practices

Daily Workflow

1. Morning:
   • Review overnight ERA postings
   • Check for new rejections
   • Review work queue / pending items
2. Throughout Day:
   • Create claims as services are documented
   • Save to WIP if waiting for information
   • Run audit before leaving claim
3. End of Day:
   • Batch audit all WIP claims
   • Batch submit all audit-passed claims
   • Clear work queue
   • Run productivity report

Data Entry Best Practices

• Always verify patient eligibility before creating claims
• Double-check diagnosis codes - must support medical necessity
• Verify modifier usage - incorrect modifiers cause denials
• Link diagnosis pointers correctly - each service must point to supporting diagnosis
• Use templates for common scenarios - saves time and reduces errors
• Review audit results carefully - don't ignore warnings
• Save work frequently - use "Save to WIP" often
• One claim per patient per date - prevents duplicates

Quality Control

• Run audit on every claim before submission
• Review claim summary before submitting
• Spot-check claims for accuracy weekly
• Track your rejection/denial rate
• Address patterns in rejections/denials
• Keep provider information up to date
• Maintain current payer enrollment lists

Compliance Tips

• Timely Filing: Submit claims within payer deadlines (typically 90-120 days)
• Accurate Coding: Only use codes supported by documentation
• No Upcoding: Use appropriate E/M level codes
• Modifier Usage: Apply modifiers only when appropriate and documented
• Documentation: Ensure supporting documentation exists for all services billed
• ABN Forms: When required, ensure Advance Beneficiary Notice is signed

Keyboard Shortcuts

Navigation Shortcuts

Claim Form Shortcuts

Frequently Asked Questions

Q: Can I work on multiple claims at the same time?

A: No, the system only allows one claim form open at a time. You must save or close the current claim before creating a new one. This prevents confusion and ensures data accuracy.

Q: What happens if I close a claim without saving?

A: If the claim is in Draft status and you haven't clicked "Save to WIP", your changes will be lost. Always click "Save to WIP" to persist your work to the database.

Q: Can I edit a claim after submitting it?

A: No, once a claim is submitted, it cannot be edited. If you need to make corrections, you must create a corrected claim or void and resubmit.

Q: How long does it take for claims to be accepted or rejected?

A: Clearinghouse typically processes claims within 24-48 hours. You'll see status update to Accepted or Rejected within this timeframe.

Q: What's the difference between Rejected and Denied?

A: Rejected means the clearinghouse found technical/formatting errors and did not forward to payer. Denied means the payer received the claim but refused payment for medical/policy reasons.

Q: Can I delete a submitted claim?

A: No, submitted claims cannot be deleted. You can only delete claims in Draft, Work in Progress, or Audit Failed status.

Q: How do I know if a claim was paid?

A: Check the ERA tab for payment postings. When payment is received, claim status updates to "Paid" or "Partial Payment" and payment details appear in the ERA.

Q: Why does my claim keep failing audit?

A: Review the specific audit error messages. Common issues include missing required fields, invalid code formats, or duplicate claim detection. Fix each error listed and re-run audit.

Q: Can I submit a claim to multiple payers?

A: For coordination of benefits (COB), submit first to primary payer. After primary pays, create new claim for secondary payer including primary payment information.

Q: What should I do if I don't know a diagnosis or procedure code?

A: Use the code search feature in the form. Type a description and the system will suggest matching codes. For diagnosis codes, consult the provider's documentation. For procedure codes, refer to the CPT manual or provider's superbill.

Training Resources

Getting Started

• New User Orientation: Contact your manager to schedule orientation session
• System Demo: Watch recorded demo videos in the Help Center
• Practice Environment: Use test tenant to practice claim creation

Continuing Education

• Coding Updates: Review ICD-10 and CPT updates annually
• Payer Policy Changes: Subscribe to payer newsletters
• Compliance Training: Complete annual HIPAA and compliance training
• Product Updates: Review release notes for new features

Additional Resources

• CMS-1500 Form Guide: Reference guide for form fields
• Place of Service Codes: Complete list of POS codes
• Modifier Quick Reference: Common modifiers and usage
• Denial Code Reference: CARC and RARC code lists
• Payer Contact List: Provider relations phone numbers

Getting Help

• Technical Support: Contact IT help desk for system issues
• Billing Questions: Consult with billing manager or senior biller
• Coding Questions: Consult certified coder or coding supervisor
• Payer Questions: Contact payer provider relations