Topics Set Claim/s Status / Parameters Search:  
Introduction: Using this popup, the user can set the status or parameters of claims. On clicking the Set Claim Status option from the vertical ellipsis for a single claim or by clicking the Set Claim/s Status / Parameters icon for multiple claims, the Set Claim/s Status / Parameters popup is invoked. This popup displays the selected Claim IDs followed by radio buttons for selection. These include:
  • Mark Claim/s as Reviewed for Eligibility
  • Mark Claim/s as Reviewed for Coding
  • Fetch Pri/Sec Ins Eligibility for DOS
  • Mark Claim/s Ready To Send
  • Ignore Warning/s and Mark Claim/s Ready To Send
  • Claims Batch (Please Select the Batch)
  • On Hold (Please Select the Reason)


    • Their functionality is explained below:

    Mark Claim/s as Reviewed for Eligibility: Select the Mark Claim/s as Reviewed for Eligibility radio button and click the OK button to mark the claims as reviewed for eligibility. The Eligibility Reviewed column on the Approve Claims screen displays the keyword 'Reviewed' for claims that have been marked as reviewed for eligibility. If the claims have not been marked as reviewed for eligibility, then the Eligibility Reviewed column is shown blank.
    Note:
    • Insurance and Self-Pay claims can be marked as reviewed for eligibility.
    • The Eligibility Reviewed condition is mandatory for marking Self-Pay claims as Billed. Once the claim status of Self-Pay claims is changed from Entered to Billed, these records are removed from the Approve Claims screen.
    • Penalty Invoices and Employer claims cannot be marked as reviewed for eligibility, as eligibility is not applicable to them.

    Mark Claim/s as Reviewed for Coding: Select the Mark Claim/s as Reviewed for Coding radio button and click the OK button to mark the claims as reviewed for coding. The Coding Reviewed column on the Approve Claims screen displays the keyword 'Reviewed' for claims that have been marked as reviewed for coding. If the claims have not been marked as reviewed for coding, then the Coding Reviewed column is shown blank. The 'Reviewed' keyword can be removed from the Coding Reviewed column by unchecking the Coding Reviewed checkbox on the ICD Pointers for Charge Codes popup for the selected claim.

    Fetch Pri/Sec Ins Eligibility for DOS: Select the Fetch Pri/Sec Ins Eligibility for DOS radio button and click the OK button to fetch eligibility for both Primary and Secondary Insurance (if present). A hyperlink is then displayed under the Clm Pri. Eligibility Details and Clm Sec. Eligibility Details columns, respectively. On clicking the hyperlink, the Insurance Eligibility popup is invoked for the user to check the details.
    Note:
  • If the last fetched eligibility is within a 14-day timeframe (7 days prior to the DOS and 7 days after the DOS), then eligibility should not be fetched. If the eligibility is other than Active, then irrespective of the timeframe, the user should be able to fetch the eligibility.
  • For TPA, Self-Pay, Employer Claims, and Penalty Invoices, when the user selects the Fetch Pri/Sec Ins Eligibility for DOS radio button and clicks the OK button, an alert message, Eligibility is not applicable to Self Pay, Employer Claims & Penalty Invoices – Claim ID/s is displayed in a popup with an OK button.


    • Mark Claim/s Ready To Send: With the property claim.review.mandatory.mark.ready2send set to ON, select the Mark Claim/s Ready To Send radio button and click the OK button. The claim status is changed to Ready To Send if:
  • Claims have been reviewed for eligibility
  • Claims have been reviewed for coding
  • Claims with 0 errors
  • Claims with 0 warnings
  • The claim is in Entered status

    • With the property claim.review.mandatory.mark.ready2send set to OFF, select the Mark Claim/s Ready To Send radio button and click the OK button. The claim status is changed to Ready To Send if:
  • Claims with 0 errors
  • Claims with 0 warnings
  • The claim is in Entered status

    • Note:
  • When the property claim.review.mandatory.mark.ready2send is OFF, Eligibility and Coding reviews are not required; hence, the radio buttons, Mark Claim/s as Reviewed for Eligibility and Mark Claim/s as Reviewed for Coding are not displayed on the Set Claim/s Status / Parameters popup.
  • When the Mark Claim/s Ready To Send radio button is selected and the OK button is clicked on the Set Claim/s Status / Parameters popup, then the message, XX Claims marked as Ready to Send out of YY Claims is displayed in a popup with an OK button.


    • Ignore Warning/s and Mark Claim/s Ready To Send: With the property claim.review.mandatory.mark.ready2send set to ON, select the Ignore Warning/s and Mark Claim/s Ready To Send radio button and click the OK button. The claim status is changed to Ready To Send if:
  • Claims have been reviewed for eligibility
  • Claims have been reviewed for coding
  • Claims with 0 errors
  • The claim is in Entered status

    • With the property claim.review.mandatory.mark.ready2send set to OFF, select the Ignore Warning/s and Mark Claim/s Ready To Send radio button and click the OK button. The claim status is changed to Ready To Send if:
  • Claims with 0 errors
  • The claim is in Entered status

    • Note:
  • When the property claim.review.mandatory.mark.ready2send is OFF, Eligibility and Coding reviews are not required; hence, the radio buttons, Mark Claim/s as Reviewed for Eligibility and Mark Claim/s as Reviewed for Coding are not displayed on the Set Claim/s Status / Parameters popup.
  • When the Ignore Warning/s and Mark Claim/s Ready To Send radio button is selected and the OK button is clicked on the Set Claim/s Status / Parameters popup, then the message, XX Claims marked as Ready to Send out of YY Claims is displayed in a popup with an OK button.


    • Claims Batch (Please Select the Batch): If the property use.claims.entry.batch is OFF, the Claims Batch (Please Select the Batch) radio button is enabled but the dropdown is disabled, whereas if the property use.claims.entry.batch is ON, both the Claims Batch (Please Select the Batch) radio button and dropdown are enabled for the user to select a claim batch. The Claims Batch (Please Select the Batch) dropdown consists of all open claim batches stored on the Settings → Claim Batches screen. Along with the claim batch number, the Claims Batch (Please Select the Batch) dropdown displays the Batch Creation Date, the code of the location assigned to the batch, and the code of the business unit assigned to the batch. Select the appropriate batch and click the OK button.
    Note:
  • If the batch has the same Batch Creation Date as the claim DOS, then the message, Batch is Associated Successfully. is displayed in a popup with an OK button.
  • On trying to associate a claim batch with multiple claims, the message, Batch is assigned to XX Claims from YY selected Claims is displayed in a popup with an OK button.
  • If the batch is not associated, then the message, Batch is Not Associated. is displayed in a popup with an OK button. A few reasons why a claim batch might not get associated are: the Batch Creation Date is prior to the claim DOS, the batch is already assigned, the claim status is On Hold, a claim having a batch assigned is reopened, the property use.claims.entry.batch is OFF, or a claim having no batch assigned is reopened and the property use.claims.entry.batch is then set to ON.


    • On Hold (Please Select the Reason): If the user selects the On Hold radio button, then selecting the reason to keep the claim on hold is mandatory. If the reason is not selected, then the error message Please select On Hold Reason while marking the claim On Hold is displayed.
    Note: Claims that are kept on HOLD revert to Entered status if any of the claims display built-in validations, Scrubbers, CCI edits, Global Period edits, or Medical Necessity edits.

    See Also: ICD Pointers for Charge Codes | Approve Claims