On the left side of Edit Claims screen, there are 3 buttons in green on the toolbar: Add, Search and Filter.
Add:
The icon enable users to add new claims.
On clicking this icon, the Create New Claim popup is invoked.
The popup shows 3 radio buttons: Create New Claim, Create a copy of an Existing Claim with New Visit ID and Create a copy of an Existing Claim with Same Visit ID.
Search:
On clicking this icon, the Claims search popup is invoked where user can search claims in Ready to Bill (E), Ready to Send (S), Billed (B), On Hold (H) and Void Claim (V) status.
Sort functionality is applicable for each column on this search popup.
The navigation buttons on this popup are used to navigate between pages.
This search popup does not show Archived Claims and Penalty Invoices.
Filter:
This icon is used to filter the claims depending on different criteria.
This Filter icon turns green in color as the filter value is applied and the search displays all the claims which fall in the entered filtered criteria.
All Claims dropdown: Claims are displayed on the Edit Claims screen and on the Claims search popup based on the option selected from this dropdown. This dropdown shows 3 values:
- All Claims: When the All Claims option is selected, then the search popup displays all the claims whether they are in Billed (B), Ready to Bill (E) or Ready to Send (S) statuses.
- Billed: When the Billed option is selected, then all the claims that are Billed (B) status are displayed in the search popup.
- Non Billed: When the Non Billed option is selected, then all the claims that are either in Ready to Bill (E) or Ready to Send (S) statuses are displayed in the search popup.
Navigation icons: First, Previous, Next and Last are the 4 navigation icons available on the toolbar to navigate between claims on the Edit Claims screen. These navigation icons are governed by the Claims search list. For example, if the current claim is 3rd in the search list and there are total of 1500 records in the Claims search popup, then clicking on First will take the user to the first claim in the list, clicking on Previous will take the user to the 2nd Claim, clicking on Next will take the user to the 4th Claim in the list and clicking on Last will take the user to the 1500th Claim i.e. the last Claim in the search list.
Note: Next is NOT in chronological Order, it is in reverse chronology OR in order of display in the search list.
Preview:
Preview gives fair idea to user about which information is going to be printed on CMS 1500 or Send via EDI 837.
Preview does not actually print claim by CMS1500 or send claim via EDI.
The User can view the following options on Preview button:
- Primary Insurance CMS as ICD 10
- Secondary Insurance CMS as ICD 10
- Tertiary Insurance CMS as ICD 10
- Primary Insurance EDI as ICD 10
- Secondary Insurance EDI as ICD 10
- Statement for DOS
- Primary Insurance UB04 as ICD 10
- Secondary Insurance UB04 as ICD 10
- Alternate CMS 1500
- CMS 1500 for Employer
- CMS 1500 for TPA
- CMS 1500 For Patient as ICD 10
- Patient Insurance EDI as ICD 10
Print:
The Print button is used to print the claim.
Users have the following options on Print popup:
Primary Insurance CMS as ICD 10, Secondary Insurance CMS as
ICD 10, Tertiary Insurance CMS as ICD 10, Primary Insurance UB04 as ICD 10,
Primary Insurance UB04 as ICD 10, Statement for DOS and Alternate CMS1500.
This popup has OKand CANCEL buttons.
Shortcut Key:
Clicking on the Shortcut Key icon invokes a popup which displays a list of shortcut keys provided on Edit Claims screen.
The supported browsers for shortcut keys are Google Chrome and Safari.
To implement shortcut keys on Edit Claims screen, ctrl+e key approach needs to be used.
Properties: This button is exclusively visible to users with Read Access to the Properties Master screen. Access to this button is strategically granted to enhance user functionality. Clicking the Properties button triggers a popup, presenting a list of properties from the
Properties
Master screen in PrognoCIS that cater to
Edit Claims.
Patient: Displays the name of the patient as a hyperlink. Clicking on the hyperlink invokes the Patient information popup. Users can make the desired changes related to patient information from this popup.
Patient Billing Notes:
A user can add important billing notes for the patient in the Patient Billing Notes popup invoked by clicking on this icon.
Notes once entered in this popup cannot be edited/deleted.
The dollar sign of the icon turns red after notes are added.
Newly added notes appears on the top and old notes move down.
Patient Notes:
A click on this icon invokes the Patient Notes popup which displays additional information or notes related to the patient.
Rendering Doc: Displays the name of Rendering Provider entered on Start New Encounter screen or Create New Claim popup. The Rendering Provider is transferred to Billing Module when the claim is 'Billed' on Encounter Close screen and the Non Billing checkbox is unchecked on Provider Master. Rendering Provider for a claim can be changed using the
icon.
Claim Id: Claim Id is the unique Id auto-generated by the system and associated to the claim as soon as it is created. It is a one up number which is incremented by 1 each time new claim is created. Claim Id cannot be edited. On clicking the hyperlink, the Claim - Last Update Details popup is invoked which displays update history of the claim. This popup displays information in three columns: Code - which displays charge code level updates, User - Last user who had updated the claim and Timestamp - Date and time at which the claim was updated.
Attach icon:
Using this icon, user can attach documents to the claim from their system.
The icon only attaches documents with extension .jpg, .gif, .jpeg, .bmp, .tif, .tiff and .pdf.
If a user tries to attach a document with any other extension then on attach, an alert message saying
"Only Specified Extensions Allowed: jpg, gif, jpeg, bmp, tif, tiff, pdf" is displayed.
On successful attachment of document, a message saying
"The file is attached and saved" is displayed.
The attached documents can be viewed only for that particular Claim Id.
(There are two ways to view attached document - Claims Screen and on Attach icon).
View icon: User can view the attached document by clicking on this icon. This icon is greyed out when no document is attached.
Additional Claim Info:
Invokes the Additional Claim Information popup which displays additional encounter, medical and other claim details that will be sent to Insurance.
UB04 Claim: Enabled icon UB04 denotes that current claim is UB04
claim (Institutional Claim). Clicking on the icon invokes UB04 form popup.
Progress Notes icon:
This icon gets enabled only when the claims is created from EMR side.
If the claim is created from Billing module then the icon remains disabled.
Clicking on the icon invokes the Review Progress Notes popup with four tabs: Default, My Notes, Attach and Procedures.
When the Encounter is opened then Default tab is displayed as selected, and when encounter is closed then by default My Notes tab is shown selected.
If any document is attached to the claim then it is displayed under Attach tab and when if any procedure is performed on the patient then those details are displayed under Procedures tab.
Claim Ledger icon:
It displays all the details related to payments received against claims (charge code wise details).
The details are displayed only for Billed claims.
If the claim is in Entered status, then no details are displayed on clicking the Claim Ledger icon.
If any charge code is marked as void then that entry is also displayed on the popup in red color.
Claim ledger can also be printed by clicking on the print button.
Assign To icon:
This icon invokes an Assign To popup which helps users to document specifics of assignments.
The popup is divided in two halves for ease of navigation and understanding.
The left side of the popup is designed to list the assignment details and the right side is to document actions taken by the assignee.
The header section lists task related activities such as: Claim ID, Claim ID and Patient Name and DOB.
Tasks which are not related to claims or patients simply list the task ID generated internally in the header row.
Denied Charge Code to take Action icon:
This icon invokes an Insurance Denied popup so that while working on a claim, a user can have a look at all Denied (No Action/WIP Action) claims so that appropriate action can be taken and user can close all pending tasks of that patient.
This popup is divided into 2 parts: ERA information which is Denied, and Actions which user must take on these ERAs.
The icon is enabled only when claim is in Billed status and there is at least one claim of that patient where Denied No Action or WIP has been received.
Only Those claims ERAs are listed in this popup for which Denied NO action or WIP has been taken for Charge codes.
By default, all the ERA entries are shown as selected but if required, the user can deselect the required entries.
This icon is disabled when required action is taken for all the ERA entries.
Claim Letter icon:
This icon invokes a Claim Letters popup from where a user can send letters to various entities, for example,
sending a note referring the Patient to a specialist,
sharing Assessment and Plan to a Referring Provider,
or communicating with Patients' Insurance Company.
This popup facilitates creating these letters quickly, using predefined templates with reference to the current Encounter so all the details are available.
Claim Notes icon:
This icon invokes a Claim Notes popup where users can write notes about the Claim for internal documentation.
Notes once entered can neither be deleted nor edited.
The header section of the popup displays the Claim ID followed by Claim Date on the left side and Patient name and DOB on the right side.
Newly added Claim Notes are seen at the top followed by older Claim Notes.
DOB: Displays the date of birth of the patient after fetching it from Patient Registration screen. It is helpful to identify a patient if another patient with the same first and last name exists in the system. The DOB is displayed in red if the patient is a minor. On hovering the mouse over the DOB, the tooltip displays the current age of the patient. This helps the User to quickly validate the assigned ICD/CPT/HCPC codes based on the patient’s age.
Patient Insurance:
Patient insurance is denoted by an umbrella icon.
Clicking on this icon invokes the Patient Insurance popup which shows the insurances associated to a claim.
Claim can have three types of insurances associated: Primary, Secondary and Tertiary.
Based on requirement, user can assign or change the Primary, Secondary and Tertiary Insurances.
When an Insurance is associated to a patient or claim, the umbrella icon turns red.
.
There can be multiple scenarios where user may need to assign Secondary and Tertiary Insurance after the claim is processed and sent to Primary Insurance.
For the Employer Claims: The Pri field is displayed as Employer - Employer Name.
For the TPA Claims: The Pri field is displayed as TPA - TPA Name.
Patient Alert icon:
Clicking on the Patient Alert icon invokes a popup that displays alerts which work as a reminder for the user regarding the patient.
There are several parameters that govern the occurrence of the alerts popup.
Alerts can be added from the My Alerts tab on this popup.
After the alert and saved, the Patient Alert icon turns red.
The icon is governed by three
properties:
- patient.alert.hide.afterdays: This property decides the maximum number of days for which an alert is visible from the day alert is created (Effective from date).
- facesheet.showalert.fortypes: This property controls the occurrence of patient alert popup. Here out of all parameters, PA controls the patient alerts.
- appointment.show.patientalert: Occurrence of patient alert popup on the Appointment screen is governed by this property. If this property is turned On, then the patient alert popup is shown on load of the screen. If the property is turned Off, then the patient alert popup is not displayed. However the Patient Alert icon continues to be displayed as red if a valid alert is present.
-
patient.alert.message.on.send2collection: This property governs custom alerts shown on the patient alerts popup when claim is sent to the Collection Agency.
Any alphanumeric message up to 500 characters can be entered in this property along with some tags like
_CANAME_ for Collection Agency Name,
_OSAMT_ for Amount moved to Collection Agency,
_CLAIMIDS_ for Claim Ids moved to Collection Agency,
_CATEL1_ for Work Telephone1 of Collection Agency,
_CATEL2_ for Work Telephone2 of Collection Agency
and _TODAY_ for Run date in MM-DD-YYYY format.
- When a message is defined in the property, the alert is displayed in the following format: Message defined in the property with appropriate tags By: System MM-DD-YYYY.
- When the property is kept blank, the following alert is displayed: Patient Claim Ids:XXXXX Sent to Collection Agency:XXXXXX on MM-DD-YYYY By: System MM-DD-YYYY.
- When claim is rolled back to the Collection Agency, the following alert is displayed: Patient Removed from collection Agency By: System MM-DD-YYYY.
Amt Paid: This is the upfront payment (Copay) collected from patient. When this hyperlink is clicked, a Patient Payments popup is invoked which displays details about CoPay, Deductibles, Visit, Advances etc.
Chart No: The chart number is added from the Patient Registration screen from EMR module and is displayed here. This is typically entered for completing the backlog of existing patients at the clinic.
Post Date: This is the date on which claim was processed. It could be between visit date and date on which claim is processed. It is a manual and editable field. Post date cannot be changed once claim is processed. To alter post date of a processed claim, the processed claim needs to be re-opened. The admin-level property set.claim.post.date.on.first.bill can be used to decide which date is to be set as the post date for a claim, as follows:
- If the property is turned On, then the date on which the claim is billed is set as the Post Date and the field is greyed out and cannot be edited after the claim is billed.
- If the property is turned Off, then the Post Date selected by the user on Edit Claims screen is set as the Post Date.
Employer Invoice: The Employer Invoice number displayed on the Edit Claims screen is hyperlinked, allowing users to directly access the Employer Invoice.
Batch Number: An EDI batch number is generated if Claim is sent via EDI. This Creation of Batch number is dependent on the property 837.oneclaim.perbatch. If this property is turned On, then one EDI Message is generated per claim and hence a separate EDI Batch No. This EDI Batch No. is displayed on the claim. By default, this property is turned On. When turned Off, all selected claims for processing from all Insurances are considered in one EDI message and all these claims get same EDI Batch No. assigned. If further, separate batches are required for specific payors, then their Payor IDs should be added in the property 837.inswise.payorids4claimsbatch. This property defines a comma separated list of Payor Ids for whom single EDI message will be generated for multiple claims, or if set to ALL, then all selected claims for processing from all Insurances are considered in one EDI message and all these claims get same EDI Batch No assigned.
Pre Auth Hyperlink: It is valid PreAuth No. received from the Insurance company. It is hyperlinked and displays active and inactive Pre Auth details in chronological sequence with open PreAuths at the top and closed at the bottom.
Status: Displays the status of the claim. The following statuses are available:
- Ready to Bill - It is denoted as E and indicates that the claim is created and saved and no action is performed.
- Ready to Send - It is denoted as S and indicates that all EDI validations are executed and claim is ready to send to the Insurance. Once the EDI/paper claims for Insurance/patient are generated, this claim cannot be edited. Claim with this status can be seen on the Claims → Send → Professional screen.
- Billed - It is denoted as B and indicates that the claim has been billed.
- On Hold - It is denoted by H and indicates that the claim is kept on hold for further clarification on billing data. Once a claim enters into On Hold status, it must be reopened to be resent. When a claim is reopened, a Reopen label appears in red color to indicate that the claim was reopened.
- Void - Indicates that the claim is voided. Once a claim is voided, it is not considered for any financial transactions or reports.
- Archived
ICD Table: This table contains Diagnosis Codes, which are entered by a Medic within the EMR module. These codes are then transferred from the Assessment screen to the Edit Claims screen when the encounter is closed and Claims are generated. In this section, the Biller can add, update, or delete these codes as necessary.
However, when Claims are created from the Claims → New screen, the ICD codes are not readily available. Instead, they must be manually entered using the Add
icon at claim-level.
The maximum number of ICDs that can be entered is determined by the property cms1500.max.icds, which is set to a default value of 12.
This table displays the following columns:
- Del Checkbox: Selecting this checkbox and clicking on the save button deletes the ICD code.
- ICD 9: ICD 9 codes can either be entered manually or can be selected from the Diagnosis Codes popup invoked via the Add icon.
- ICD 10: Just like ICD 9, ICD 10 codes can also be entered either manually or can be selected from the Diagnosis Codes popup.
- Name: This column displays the description of the selected ICD code.
- Add icon: Clicking on this icon invokes the Diagnosis Codes popup of IMO search for ICD9 and ICD10 codes.
- Preferred: There are three types of preferred list, CP – Clinic preferred, MP – Medic Preferred and DS – Doctor Specialty. Preferred list changes with the change in login entity. The popup displays Description followed by ICD9 codes, ICD10 codes, SNOMED Int'l and Type. Column ICD9 display the list if ICD9 codes, column ‘ICD10’ display ICD10 codes corresponding to ICD9 codes. Mention about SNOMED Int'l and column Type displays the preference type, like CP – Clinic preferred, MP – Medic Preferred or DS – Doctor Specialty. In the preferred list user can view Standard ICD codes which are added in preferred.
- General: When this tab is selected it displays this list of general ICDs. As user click on General tab, popup shows blank screen. user has to give input of 3 characters and after that auto search is invoked, which gives liSt of all ICD codes where entered 3 characters are found in either code (ICD 9 Or ICD 10), or in ICD description, or in SNOMED. If user enters exact ICD number, then the list of that exact ICD code is given where it might have different Description and different Snomed combination.
- Custom: This column displays the list of custom ICDs created manually.
- Drill Down: From the General tab, users have provision to select ICD 10 codes alternatively to the preexisting ICD 9 code – this provision gives User a choice to select the appropriate code for the appropriate diagnosis at a granular level. For example, ‘Pregnancy' has same ICD 9 code for several different conditions in pregnancy whereas the ICD10 codes have multiple and varied codes for these conditions. Whereas, on the Drill Down tab, for each of these specific conditions there is a possibility for a User to ‘DRILL' the Search further to get to the exact ICD10 code that depicts the patient's pregnancy condition very specifically. The provision to actually drill further on the IMO search popup and find the appropriate ICD10 codes for the condition experienced by the Patient is the functionality available on the 'Drill-Down' tab. UI of Drill Down tab is quite different from other tabs. Icons present in the Drill Down screen are:
Business Unit: This dropdown displays the names of various business units defined on Settings → Configuration → Clinic column → Business Unit where services are rendered to patients. The default selection in this dropdown is based either on Encounter Type or Location based on the four admin-level properties: claim.bucode.by.enctype, claim.bucode.by.location, claim.bucode.by.location2 and claim.bucode.by.location3. The system prioritizes the claim.bucode.by.enctype to determine the Business Unit for the claim. If the specified encounter type is not utilized in the claim, the system checks the location property claim.bucode.by.location to populate the Business Unit. If no locations are specified, it looks at subsequent location properties claim.bucode.by.location2 and claim.bucode.by.location3. If none of the above properties are utilized, the system defaults to the Business Unit of the claim's Rendering Provider, as established in the Provider Master. In the event that the Rendering Provider's Business Unit is inactive, the earliest created Business Unit is populated after examining all conditions.
Place of Service: This dropdown allows the selection of the name of the location where the service was rendered to the patient. The options displayed in the dropdown are configured from Settings → Configuration → Groups column → Group Types → B5 - Place of Service. For Telemedicine visit type, this is set to the claim's Location if the property prognocis.telemed.use.loc.pos is turned On from the Properties Master screen, else it is set to 10 – Telehealth Provided in Patient’s Home.
Type of Service: This dropdown allows the selection of the type of service rendered to the patient. The options displayed in the dropdown are configured from Settings → Configuration → Groups column → Group Types → B4 - Type of Service.
Financial Class: This dropdown allows the assignment of a financial class to the Claims. The dropdown options are configured from Settings → Configuration → Groups column → Group Types → B3 - Financial Class. This financial class is automatically updated if the financial class information of the claim is changed via the Update Claims icon on Outstanding Claims, Assigned Tasks and Processed Claims screens.
Accept Assignment: ‘Assignment’ means that a Provider agrees (or is required by law) to accept a Medicare-approved amount as full payment for covered services. Essentially, by saying that the office will accept assignment, Clinics are agreeing to the payment amount being covered by the insurer or Medicare, and the patient has no financial responsibility. This dropdown indicates relationship between the Provider, Payer and Insured. This dropdown controls Loop2300 CLM07 & CLM08 segments. Refer to the table below to note the values transmitted when the respective options are selected from the dropdown:
Selected Value |
Provider is Contracted Loop2300 CLM07 |
AOB on File Loop2300 CLM08 |
Comments |
|---|---|---|---|
| Assigned | A | Y | Indicates Provider is Contracted and Patient signs AOB |
| Assignment Accepted on Clinical Lab | B | N | Indicates Lab services provider is contracted. Patient need not sign AOB |
| Not Assigned | C | N | Indicates Provider is Not contracted and Patient need not sign AOB |
| Patient Refuses to Assign Benefits | C | W | Indicates Provider is Not contracted and Patient has Not signed AOB. Payment would go to Patient for such services. |
Fee Schedule: Fee Schedule in PrognoCIS is a list of amounts defined for Charge Codes which can either be standard codes such as CPT & HCPCS, non-standard codes, items, DME or special billing codes. This dropdown lists all the Fee schedules marked as Special on the Fee Schedule screen (Settings → Fee Schedule). Users can select an appropriate fee schedule before sending out the claim. On selection, the fees would get calculated automatically for charge codes marked as Self Pay. The Fee Schedule applicable to Claim is determined by following factors according to the priorities in the order mentioned below:
- Date of Service of the Claim
- Business Unit
- Location Code
- Insurance Company
- Rendering Provider
- Status of Out of Network checkbox of Insurance Company
Work Comp Employment / Auto Accident / Other Accidents / Provider SOF / Pregnancy / Payment Plan / Bill to Employer: Accidental claims can be created when encounter type is defined as Work Comp or Auto Accident, and patient insurance is Workers Comp or Auto accident. A user can create an accidental claim directly from Claims → New Claim by selecting Encounter Type as Workers Compensation. If a user creates a claim with Encounter Type as Workers Compensation but insurance is not defined as Workers Comp, then on checking the Ready to Send checkbox and clicking save, a message: Pri Ins status is not Workers Comp is displayed. If the patient does not have any Insurance and on Claims → New Claim screen, if the user select Encounter Type as Workers Compensation, then a self-pay claim gets created, which does not have Workers Comp checkbox checked. These check boxes govern whether the created claim is an accident claim type or not. When any of these check boxes are checked, then all three checkboxes are heighted in Red. At one time, users are allowed to check only one checkbox. When any of these check boxes are checked then injury... button gets enabled. This button helps the user add injury related information. The information entered on injury... button gets stored in the i button on save of claim.
Provider SOF: This is Patient Signature on file. It is the authorization/consent given by a patient to release any medical or other information to process claims. By default, Provider SOF is checked and grayed out. It is printed in Cell12 and Cell13 (Insurance subscribed by other and used by patient).
Pregnancy: The workflow of this checkbox is governed by the property billing.enable.pregnancy.cb. If this property is turned On, the Pregnancy checkbox is checked irrespective of the status on the EMR module. If this property is turned Off, then the status of the Pregnancy continues to remain as it was initiated on the EMR side. This property is set to Off by default.
Payment Plan: The Payment Plan checkbox is automatically checked and displayed in red and bold font for a patient having an assigned Patient Payment Plan. User may uncheck it later. The tooltip displayed on the Payment Plan checkbox displays Plan Name, Installment Amount and Next PayDate.
Bill to Employer: The Bill To Employer checkbox is checked when the claim is an Employer Billing claim. When a valid Employer is associated to a patient on the Contacts tab on Patient Registration screen and the claim is either created from Encounter Close screen or from Claims → New Claim screen, then Bill To Employer checkbox is checked automatically. When Employer Billing claim is created from EMR side, the claim's encounter is set to the Enc Type on i button as it is set on patient's appointment. Please refer to Employer Master Help for more details.
Add: From the dropdown user can select the type of codes they wish to add in the Claim. Types of Charge applicable are:
- CPT
- HCPC
- Spl Charges
- Revenue Items (Available only when the Claim is UB04)
- Items
- DME
Rearrange CPT/HCPC List
: When the property, billing.sync.with.emr is set to 'Y - Encounter Closed' or 'L – Encounter Open,' the sequence of CPT/HCPC rows on the Assessment screen is carried over to the Edit Claims screen. The Rearrange CPT/HCPC List icon is enabled only for Claims that are in ’Entered,’ ’Ready to Bill,’ or ’On Hold’ Status. Click the Rearrange CPT/HCPC List icon to invoke the Rearrange CPT/HCPC List popup, which displays the Type, Code, and Description of the selected Charge Codes which include CPT, HCPC, Special Codes, Items, DME. You can drag and drop rows to the desired position in the list using the 
icon to rearrange the selected Charge rows.
Buttons Governing Charge Code
EMR Codes: After Claim is created from EMR side, when doctor add CPT/HCPC/Modifiers and ICD's to Assessment and load the Claim without visiting the Encounter close screen, then on load of Claim user gets validation message saying Assessment has been changed after last save of Claim. This is when EMR code button is enabled and on clicking the button user can add changed assessment data on Claim.
Copy Codes: The purpose of this button is to enable user to copy CPT/HCPC Codes for the Patient from his existing Claims. Codes will get copied despite of the fact whether the claim is in Billed statuses.
CrossOver: Usually, it is not recommended to send non-standard code to Insurances, CrossOver feature enable users to cross over the non-standard CPT/HCPC with the defined CPT/HCPC along with modifier. This functionality is used to change or replace one code with another. For example, on CPT Master for charge code 99203, a CoCPT 99213 is defined with modifier 21. Now, whenever 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.
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. A .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.
Claims Hx: Claim history button reflects details of all the claims that are associated to the patient. Details displayed on Claims History popup includes Claim Id, Service Date, Hospital From and upto date, Location, Provider, ICD9 Codes, ICS 10 Codes, Charge Codes, Modifiers, Type and Bill Amt.
Attach: User can send Claims Attachment for 2 clearing Houses: P2P and Gateway. For P2P many time Clinic need to visit older documents for patients, especially in case of Work Comp Claim. For Ex PR2, PR4 forms along with Chart Notes etc. So now, When Claims Clearing house is P2P and claim is work Comp type, then user can send Claim attachments to Clinic through P2P clearing house.
Denials: The buttons displays all the Denial details. Clicking on the button invokes a popup displaying all the details related to denials like Claim Id, Claim date, EOB No, Payor, Pri/Sec/Ter, Charge Code and Denial reason.
Fields on Charge Code Detail Frame
If the Claim is in Billed status then all buttons present in that charge row except CMS flag button are disabled. Further, if the Claim is in re-opened status then Modifiers, Pointers, ICD 10 Codes Search Button, CMS flag, From date, Upto date and Comments button gets enabled.
Del: On checking the checkbox and save the charge code entry gets deleted from charge code detail frame. The check box is disabled when the claim is in Billed or Re-open status.
Code: On adding the charge code by using the binocular icon, code gets auto populated in the field. On the tool tip of the added Charge CPT/HCPC Codes user is able to view the Code and its description. For Special Charge Codes and Item Codes we are able to view Code and Name of the Code.
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. User can add modifiers from Group types → CPT Modifiers. Modifiers can be associated with charge code by following ways:
- Modifiers can be associated to Charge code through the Binocular Search Button
- Modifiers can be added manually in comma separated format or
- Modifiers can be associated to CPT Master as default Modifiers
- Modifiers can also be added from Encounter → Assessment Screen for that Charge Code.
Fee: This displays the price of the medicine or injection used in the encounter. Price is getting displayed from the fees schedule. User can also change the fee manually.
For protocol-level and test-level CPT/HCPC codes populated from Employer protocols, the Fee is populated as follows:
- For Employer encounter type, the fee for the protocol-level CPT/HCPC codes is fetched from the Employer’s fee schedule. If the Employer is assigned to multiple fee schedules, then the latest fee schedule is considered. If the amount in the fee schedule is changed and the re-calc button is clicked, then the new amount is fetched. Test-level CPT/HCPC codes are added with amount as $0.00, which can be changed manually by the user.
- For Worker’s Comp encounter type, the fee for the protocol-level CPT/HCPC codes is fetched from the Billing fee schedule or locality fee schedule, as applicable. Test-level CPT/HCPC codes are added with amount as $0.00, which can be changed manually by the user.
- For all other encounter types, the fee is fetched from the Billing fee schedule for both Protocol-level and test-level CPT/HCPC codes.
Users are allowed to add 0 amount charges on Claims and while posting a Claim system displays a validation message.
Zero Charge Rows: 1 : Do you still want to continue? If user clicks on Yes, then system mark that Claim as billed with 0 amount charge code.
Bill Pat: When the checkbox is checked the Claim is billed to the Patient. The checkbox is checked by default for all ‘Self Pay’ Claims. Depending on the type of Claim, this label changes to 'Bill Emp' and 'Bill to Pat'. User can manually check 'Bill Pat' check box, to create CMS for patient work flow.
Note:
This checkbox is checked and disabled by default for DMEs (i.e. DMEs are billed to patients).
Pointers: This field is enabled only when CPT/HCPC Codes are added to the Claim. This field is disabled when Special Charge Codes or Items are added to the Claim. Pointers get added by adding the Alphabets which are defined in the ICD Table. User can manually enter pointers without Comma. But on save of pointers those associated ICD codes get displayed on ICD 10 table as comma separated. For a single charge Code only 4 pointers can be added. When Pointers are added then on save the Pointers tab value gets wipe out and the value gets printed on ICD 10.
ICD10 codes: ICD 10 Codes, are nothing but the pointers. User can assign pointers to charge code by selecting it from Search binocular.
CMS Flag:
Clicking on the icon invokes 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.
From Date: Enter the date on which the medication started. Date can be entered either manually or by using the calender icon present next to the field. By default present date is displayed in the field.
Upto date: Enter the date on which the medication ended. Date can be entered either manually or by using the calender icon present next to the field. By default present date is displayed in the field.
Comments: User can mention comment (if any) for future reference.
Action Checkboxes
Add Tax: Users can calculate tax for a new claim or for existing claim by checking the Add Tax checkbox. The functionality will be governed by two properties claim.tax.percentage and claim.tax.charge.code
In the first property user need to set appropriate percentage value without percentage symbol. The property supports value upto 4 decimals. In the second property user need to add appropriate CPT/ HCPCS. It is only when appropriate Charge code is added to this property the Add Tax checkbox appears on Claims → Edit Claims screen
Workflow
- When the Add Tax checkbox is checked a new row will get added on the claim with Non Standard or Standard CPT/HCPCS code defined in the property. Tax amount will be calculated as per the Percentage defined in the property claim.tax.percentage.
- If the property claim.tax.charge.code is blank then Add Tax Checkbox is not displayed on Edit Claims screen.
- When a Non Standard code is added on the claim and user clicks on Add Tax Checkbox, the latest amount against the charge code will get updated.
- User can delete the code and re-add it.
- User can modify the fee; however, after clicking the Add Tax Checkbox, the amount will be recalculated.
- Add Tax will remain Checked when Tax is added on the claim
- If user deletes the Tax code (Or Charge Code defined in the property claim.tax.charge.code) from the claim then checkbox Add Tax will get unchecked.
- Tax amount will not consider the Voided Charge Codes for computing Taxes.
- When Claim is Billed & Tax is already added on the claim, Add Tax Checkbox will be disabled and checked.
- When claim is billed and Tax is not added on the claim, Add Tax Checkbox should be disabled and unchecked.
- User can change the Charge Code defined in the property: claim.tax.charge.code any time.
- If Tax code is already used on the claim and is changed Later, New code will be used to calculate the Tax on claim.
- If in the property claim.tax.charge.code a particular charge code is defined but the Claim does not have any charge code & User checks the Add Tax checkbox to add Tax on claims, PrognoCIS will add the Tax code defined in the property with $0 amount.
- If Charge Code other than Tax Code is voided after Claim is billed (By reopening the claim and using CMS Flag button), then user will explicitly have to void the charge code for Tax as well and reenter the same to ensure accurate Tax is reported on the claim.
- When Claim with Calculated Tax is reopened and user tries to add /Void or Delete Charge Codes, then user needs to ensure Tax Code also is voided. New Tax Amount on such claims has to be calculated manually.
On Hold: A claim can be kept on Hold explicitly by checking this box and worked on later. Select drop down is provided next to On Hold checkbox which will allow you to select the reason why you are putting the claim on Hold. A new Group Type is added for On Hold Reasons ie Type 'HR'. This list displayed in the dropdown and is invoked from Settings → Configuration → Group Types → HR (Claim On Hold Reason).
Ready To Send: Indicates the claims are to be Queued to be processed. By default when User clicks on Ready to Send and Saves the claim, All claims are now seen under claims → Send Claims page from where User can process the claims together. User can also send the Claim directly by clicking on the Send Button.
Action Buttons
Save: The button helps in saving the claim. The button gets enabled only when any change is made in the claim.
Send: This button helps in billing the claim. The button is governed by a property billing.disable.submit.claim, the button is displayed as enabled only when the property is set to Y. For billed claims the button send gets relabeled as re-send.
Delete: Claims can be deleted by clicking on this button. The button gets enabled only when the claim is in entered or ready to send status. It remains disabled for billed claims. For claims that are in re-opened status the button is enabled only when no voucher is received on the claim, else the button remains disabled.
Reset: Clicking on this button resets the unsaved data.
Re-calc: After charge codes are assigned to a claim and then changes are made in the fees schedule. Then clicking on the re-calc button re calculates the fees and charges.
Re-open: Clicking this button re-opens the billed claim. Enabling or disabling of this button depends on the role. If user is allowed to re-open a claim then the button is displayed as enabled else it is disabled.
Void: The button is helpful to mark a billed claim as void. The button is governed by a property billing.claim.hide.void.button the button is displayed as enabled only when the property is set to Y. When the property is set to N the button is displayed as disabled. Voided claims are recorded in the Edit Claim History popup, creating a clear audit trail for tracking voided claims based on the option selected from the Claim Void Confirmation Popup.
Split: The button helps in splitting Employer claim in to separate TPA claims. Based on the CPTs added on the claim, the split button gets enabled on Claim screen.