Encounter Close screen in EMR, has a provision to check a Status Ready to Bill. If this is checked, an Entry in the Billing table is created and can be seen under Appts tab on Billing Home Page and Claims >> Edit search list. Note that the encounter must have at least One CPT/HCPC code in its Assessment, to be able to create this entry. Secondly, on close of encounter this is assumed to be checked and treated accordingly.

Action Icon

Filter: Button ‘Filter’ is added on the screen which will replace button ‘select Filter’ (used to be at bottom) and Tool Bar List Box for ‘All/Unprocessed/Billed’(This toolbar has been also removed from screen). This Filter is indicated by the funnel icon next to Claims search binocular icon. Button ‘Filter’ will invoke pop up ‘Edit Claims Filter’ where user can enter criteria to filter out the claims to be displayed on Claims >> Edit screen. Color of the icon turns ‘Green’, when filter is applied to the screen. It indicates that ‘Filter’ is applicable on screen. Filter icon is visible on Claims > a) Edit b) Send Claims c) Send UB04 d) Outstanding e) Claims Center  f) Charges Center

List of Reopened Claims: When a claim is reopened, it is marked as ARCHIVED and a copy is made for editing. This icon lists all the archived records for these claims so that the user can see a history of all the changes made to the claim. The invoked search also displays the name of the person who had reopened it, along with the date and time, Amount, Status and Reason.User can select any of the reopened claim and load it to explore the details. When reopened Claim voucher is loaded, header portion of the voucher is highlighted with Yellow border. User can navigate to Original Claim by clicking the same button. When the search is invoked from a reopened Claim, it will list the Original Claim voucher at the beginning of search list with corresponding status. Also, other instances of reopened vouchers will be enlisted below the original voucher, allowing user either to navigate to the Original Claim Voucher or explore the other archived copies, if any.

Claim Notes: It is used to write notes about the claim for internal documentation purpose.

Progress Note: It displays the Progress note of the corresponding encounter. A Biller reads the encounter Progress note and makes an assessment, whether the CPT/HCPC codes used are right or it need to be changed. This is important since many Doctors do not enter any codes, but leave it to the Biller to do so.

Claim Additional Info: Additional Claim information like names of Attending, Rendering, and referring providers, Submitter Type, Resp Person Name, Last Seen by Doc, Last Seen Date, Home Care Contract Date, Billing Provider Type, Pay To Provider Type, PreAuthorized Visits, CLIA no., Anesthesia start and end time, Duration for Anesthesia (auto calculated by system) and dates like hospitalization, illness, injury, Pregnancy, Send to Primary, Send to Secondary, Enc Type(for Employer Billing). These are important fields required for claims as per 5010 specs.

UB04 : Enabled icon 'UB04' denotes that current claim is UB04 claim (Institutional Claim). It displays pop-up 'UB04' which has fields like 'Bill Type', 'Visit Type', 'Hosp. From Type', 'Hosp. Upto Type', 'Admission Time', 'Admission DX(important field for In Patient Type for 'Place of Service').Basic Instittional EDI claims can be created and posted from PrognoCIS.

Claim Ledger: It displays the list of all receipts/write-offs/adjustments made by insurance/patients against claim in focus. Using button 'print', details displayed on Claim Ledger can be printed.

View: Any document which is attached can be viewed.

Attach: PrognoCIS allows the user to create the claim based on CPT codes entered in assessment. For users, who are not using the EMR to its full potential, they would like to create a claim based on hand written or printed super bill. Such a reference document can be attached to the claim. Once the document is attached, the icon toggles to detach.

Track Status: tracks the claims status as in, the number of times the claim got sent, rejected, and reopened.

Patient Billing notes: It invokes a pop-up to display/add patient billing notes.

Patient Alert: It displays Patient Alert issued by Biller/Admin for a patient. When Patint Alert is present, icon is marked with red tick mark. The Patient Alert display is dependent on the parameter set in property ‘facesheet.showalert.fortypes’. When ‘PA’ is set in this property then would it display on Claims >> Edit screen.

Details about fields on Claims-->Edit Screen
Patient:  It is patient’s name whose claim is being edited.

DOB: Date of birth of the patient fetched from Patient Registration Screen. It is helpful to identify patient if duplicate first name and last name exists in the system. If patient is minor then DOB is displayed in red color.

Account No: If information about claim comes from Interface then Account No. of the Patient is sent to Insurance Company. Account No. is fetched from Patient Registration Screen.

Chart No: This is typically entered for completing the backlog of existing Patients at the clinic. Chart No. is added to Patient Registration Page from EMR module and is displayed here.

Rendering Doc:  Rendering Doc. is entered on 'Encounter' screen in EMR side. Set ' Rendering Doc.' is transferred to Billing Module when claim is 'Billed' up on Encounter close. Rendering Doc for the specific claim can be changed using ‘I’ button.

Primary: Hyperlinked 'Primary' displays insurance subscribed by the patient. It displays list of insurances subscribed by the   patient. By default, ‘Self’ is displayed if patient has not subscribed any insurance. Primary insurance is displayed if patient has Primary insurance subscribed to him. Hyperlinked 'Primary' invokes Pop-up Patient Insurance. It is extends the capability to modify insurances assigned to patient with out leaving Claims >> Edit screen. Refresh Claims >> Edit screen to reflect the changes incurred on Paient Insurance screen.

Secondary Ins: Dropdown Secondary displays the list of insurances subscribed by patient. Assign Secondary insurance to claim if subscribed by patient using this drop down. Secondary Insurance can be assigned or changed even after claim is 'Billed'.

Tertiary Ins: Dropdown Tertiary displays the list of insurances subscribed by patient. Assign Tertiary insurance to claim if subscribed by patient using this drop down. Tertiary Insurance can be assigned or changed even after claim is 'Billed'.

Claim Id: It is unique Id auto generated by the system associated to claim as soon as it is created. It is one up number which is incremented by one each time new claim is created. Claim Id cannot be edited. Claim Id on Claims--> Edit screen is hyperlinked. Click hyperlinked ‘Claim Id’ to view Claims Update History pop up. Claims Update History shows update history of edition of claims from version V2B5 onwards. Claims Update history pop up displays information about –

• Claims / Charge Code level update.
• Last user who had updated the claim.
• Last TimeStamp when modified.

DOS: It is date of service on which encounter happened.

Post Date: It is the date on which claim was processed. It could be between visit date and date on claim is processed. It is manual and editable field. Post date cannot be further changed once claim is processed. To alter ‘Post Date’ of processed claims, Processed Claims needs to be Re-opened.

PreAuth: It is valid PreAuth No. received from Insurance Company. It is hyperlinked and displays 'active' and 'Inactive' Pre Auth details in chronological sequence with 'open' PreAuth at top and closed at bottom.

Amt Paid: It is the upfront payment (Copay) collected from patient. When hyperlinked ‘Amt Paid’ is clicked, it displays pop up ‘Copay’ having details about 'CoPay', "Deductible', 'Visit', 'Advance' etc .

Sent Date:  As soon as claim is marked as ‘billed’, ‘Sent Date’  is automatically populated. This date is updated whenever claim is reopened and processed again. Therefore, Sent Date is the last updated date on which claim was reopened and processed. Dco No./ Voucher number of Billed Claim is displayed right after 'Sent Date' for 'Billed' claim.

Billing Status: There are four statuses of claims:

Claim’s status is also displayed on Billing home page.

Fee Schedule:  It is fee schedule which is applied to charge codes according to rates predefined in the fee Schedule. It is configured from Settings >> Configuration >> Codes / drugs >> Fee Schedule. If the Biller wishes to change the Fee Schedule for the applicable components from Default to other schemes like BCBC or HMO or any other, this can be achieved by selecting the desired choice from Fee Schedule list box and save. It is Important to click on the Re-Calc button to implement the changed fee schedule.

Auto Accident:  ‘Auto Accident’ is checked if Status in Patient Insurance Details screen is ‘MotorAcc’.

Other Accident:  ‘Other Accident’ is checked if Status in Patient Insurance Details screen is ‘PersonalAcc’.

Note: When either of the checkbox related to ‘WorkersComp’ or 'AutoAccident' is checked then background around those checkboxes is turned ‘Red’.

Injury: Button 'Injury' is enabled when checkbox either 'Auto Accident' or 'Other Accident' is checked. 'Place of Accident' and 'Date' is mandatory for 'Auto Accident' or 'Other Accident' claims.

Patient SOF: It is Patient Signature on file. It is the authorization/ consent given by patient to release any medical or other information to process claim. By default, ‘Patient SOF’ is checked and grayed. It is printed in Cell12 and Cell13 (Insurance subscribed by other and used by patient).

Note: When Claim is either 'Capitation Type' or 'Employer Billing', word 'CAPITATION' or 'Employer Name' is displayed in red and bold font in front of 'Bill To Employer' respectively to distinguish that claim from rest of the claims in system.

Bill To Employer: Checkbox 'Bill To Employer' is checked when claim is Employer Billing Claim. When valid Employer is assoicated to Patient on Contacts Tab in Patient Registration and the claim is either created Encounter Close or from Claims >> New screen then 'Bill To Employer' gets checked automatically. When Employer Billing Claim is created from EMR side, then claim's encounter is set to the 'Enc Type' on 'I' button as it is set on Patient's Appointment. Please refer help 'Employer Billing' to learn more about it.

Plan Payment: Checkbox 'Plan Payment' is displayed in red color and bold font for patient having assigned with 'Patient Payment Plan. It is automatically checked for such patients and having patient responsibility. Later user can uncheck it. The tooltip on the checkbox 'Plan Payment' displays Plan Name, Installment Amount and Next PayDate.

Copy Codes:  Copy Codes is good functionality which avoids re-work on assignment of ICD/Charge codes to the claim. It becomes handy tool when user wants to copy the codes from earlier claims of the same patient to the current claim for the patient.

Crossover: Crossover feature enables CPT/HCPC codes to replace the used CPT/HCPC with assigned CPT/HCPC along with modifier. For example, on CPT Master for CPT code '99203', 'CoCPT' is defined where charge code is '99213' with modifier '21'. When charge code '99203' is used in claim and button 'Crossover' is used for this charge code then existing code '99203' would be replaced with code '99213' having modifier '21'.

Note: Crossover across from CPT to HCPC and vice versa does not work.

CheatSheet: CheatSheet is a list of customized validations maintained by Clinic for different Insurances. These validations in CheatSheet evaluate the claims while processing for sending claim to insurance company. Biller can implement various validations according to the distinct requirement so that claims are not rejected by Insurance companies for stringent requirement specific to Insurance Company. Cheatsheet acts as a check list for the users to check the details filled in the claim to minimize or eliminate the possibility of rejection from the insurance companies.

CheatSheet can be created with the help of .xls file from Claims > Edit Claims > CheatSheet. An .xls file can be downloaded by clicking on the ‘Download’ icon and after defining the CheatSheet validations the sheet can be uploaded by clicking the ‘Attach’ icon.

Note: Scrubber checks feature is implemented for Insurance Claims only, not for 'Employer' and 'Self Pay' claims.

Addition of Charge Codes at Charge row level

Addition of charge codes and ICD codes depend upon type of Services rendered to the patient.

Types of Charge applicable are:

• CPT
• HCPC
• Spl Charges
• Revenue Items
• Items

Modifiers: Modifiers can be added along with CPT/HCFC Charge codes. Sequence of addition of Modifiers to a charge code is retained and displayed accordingly.

CMS Flags Pop Up: CMS Flags pop up provides capability to change few parameters associated to charge code at charge code level. 'Unit', 'Admin Qty' for NDC code can be defined on CMS flag. When user wants to discard a charge code from 'Billing' , use 'DO NOT SEND' checkbox on CMS flag pop up. 'DO NOT SEND' marked charge code is highlighted with Red color background at charge code level in a claim.

Calculation: Each Charge is essentially for a CPT Code OR HCPC Code or Sales Item Code. Please refer to Settings > Configuration > Fee Schedule menu option where the charges for each CPT/HCPC Code under a specific Schedule like "U&C" (Usual and Customary) can be defined and edited. These rates can be maintained Period wise. This way considering the Encounter Date and Schedule name defined in property, Billing Parameters > billing.uandc.schedule.name, the program knows the right table to refer to, to get the Billable rates. Please Note that these Billable rates are independent of the Insurance Company and are applicable even if the Patient does not have any Insurance. The program also refers to the Patients Insurance Master to get the Schedule under which (rather as a percentage of which) the program computes what can be expected to be paid by the Insurance Co. Special rates are defined for specific Modifier codes like TC and 26, and requisite Percentages for other modifiers.

The data on this screen is thus computed and presented. If the Patient does not have any Insurance, all Charges are booked against Patient. All Sales Items are charged by default to Patient (since they can include Cosmetics creams, reading glasses etc). The Biller has the liberty to change the rates and the allocation of amount between Insurance and Patient. Ideally, the Biller should have no need of making any entry / changes other than changing status to Ready to Send.

The Biller can also Add / Delete ICD / CPT / HCPC / Item Codes. On save the corresponding codes are Added / Deleted from EMR records provided the property, Billing > billing.sync.with.emr = Y.

Paper:

Professional / Institutional Paper Claim Insurances are printed on CMS1500 and UB04 form respectively. Checkbox 'Paper' on Claims>>Edit screen is indicates that primary claim insurance is Paper Insurance (Professional/Institutional), . As soon as, Paper Claims having Primary Insurance as Non EDI enabled are created, the checkbox 'Paper' is automatically marked by the system. Checkbox 'Paper' can be explicitly used to print 'CMS1500' for EDI insurances also.

On-Hold: ‘On-Hold’ is the status where posting of claim to Insurances is kept on hold knowingly. ‘On-Hold’ is a checkbox and when it is marked, ‘Ready to Send’ checkbox option is disabled. To resend claims ‘on-Hold’, re-open the claim and then such claims are allowed to be posted. On-Hold status is also displayed on Billing Home Page.

Ready to Send: ‘Ready to Send’ is a checkbox and it is marked to send the claims to Insurance Companies. After necessary information about claim like Patient details, Insurance details, Charge codes etc. are filled, check ‘Ready to Send’ checkbox and then click button ‘save’ to send claims to the Insurance Companies. Therefore, it is necessary to execute action on button ‘save’ once ‘Ready to Send’ is marked so that claims are posted to Insurance Companies. Once this is checked and saved, the Status will change to "Ready to Bill ". All the claim scrubbing validations for EDI claims which are also available on Claims >> Send Claims screen are carried out on action 'save' once checkbox 'Ready to Send' is marked.

save: Click button ‘save’ to post the changes done to claim. When claim is saved does not mean that claim is posted, it is merely changes are posted to database.

send: Sometimes, user might want to post the claim already ‘Billed’ claim or new claim directly to insurances right from Claims >> Edit screen, a new button ‘send’ provides the similar functionality to achieve it. This button will also allow to send the Primary and Secondary EDI claims from Claims >> Edit screen along with functionality of button ‘resend’. The button ‘Send’ has replaced button ‘resend’ on claims screen which was visible once claim was ‘Billed’. All the functionality of button ‘resend’ has been incorporated along with added functionality in button ‘Send’. This button remains enabled when claim is either in ‘Ready to Send’ or ‘Billed’ state. Whenever claim either in ‘Ready to Send’ or ‘Billed’ state is sent using button ‘send’, all the validations including EDI checks are carried out on ‘save’ of the claim once it is marked as ‘Ready to Send’.  For the first time, button ‘send’ simply posts the claim to EDI and thereafter pop up ‘Claims Resend Options’ is invoked which has listing related to post the claim either by printing CMS or post EDI ‘837 Professional’. According to association of Insurances with claim, options are appropriately listed on the pop up. Default option either for CMS print or EDI post depends on status of checkbox ‘Paper’. It is also possible to print CMS for EDI claims by just selecting the option from that pop up. Therefore, it now comes as an easy option to ‘Bill’ individual claim right from Claims >> Edit screen either by printing CMS or posting to EDI 837. Claims can be ‘billed’ even after these are in ‘Billed’ state. Button 'send' is enabled once claim is marked as 'Ready to Send'.

Note: Unless secondary responsibility is created, the option to post to respective CMS/EDI is not displayed on pop up.

delete: Click button ‘delete’ to delete the claim.

reset: Click button ‘reset’ to undo the changes incurred to claim before saving it.

re-calc: Click button ‘re-calc’ to recalculate when changes are posted to database on claims screen and displays appropriate data after refresh.

void: Consider scenario, when incorrect primary insurance was associated to the claim when it was posted, Denial or may be claim needs to be ‘rebilled’ and user wishes to discard the earlier claim. To cater these scenarios, PrognoCIS has added a functionality ‘void’.  The claim can be marked as ‘void’ under following conditions:

• Claim status is ‘Billed’.
• There is no EOB from Primary (except case of Denied with no further action taken.)

Button ‘void’ invokes pop up asking about confirmation for chosen option as stated below:

• Make this claim as Void
• Make a copy of this claim, and make current claim void.

When claim is marked as ‘void’ then

• Balance of the claims will not be displayed on ‘AR with Insurance responsibility’ or write off should not be done.
• Entry about ‘void’ claim is however displayed on Patient Account with ‘Void’ flagged for claim and ‘Billed’ amount as zero so that it does not add to the ‘Totals’.
• The claim’s status changes to ‘void claim’ and is displayed in black and bold font.