Before you can create an Insurance claim from an invoice several items must be present for the claim to be created.
For Manual Claims
1) The Patient file must contain a completed and valid primary insurance policy for the patient.
2) The Invoiced items must have valid procedure coded (CPT) and Diagnostic (ICD9 or ICD10) codes entered for the items to be billed to the insurance company. Items not having this information will not be included in a claim. (see View Details column for invoice line item)
For Automated Claims
All of the above items plus applicable eligibility rules and billing rules must exist for the given insurance policy being used. The eligibility and Billing rules are activated (calculated) when the line item is added to the invoice and the Apply Insurance check mark is checked. ( see Insurance Company Policies settings)
Create a Claim Manually
To create a manual claim click on the Claims button located on the invoice screen and in the primary insurance claims screen click on prepare/ update button. The Claim record will be created and displayed in the grid. To manually edit the claim double click on the Claim located in the grid, this will open the claim screen that you can manually edit to create the claim to be sent.
Important: This action does not submit the claim it only creates the claim. You must print (using the CMS 1500 form) or send the claim electronically to the insurance company for payment. Use the Send Claims to Insurance Company button located in the Back-Office Patient & Insurance tab.
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WEB Base Claim submission
If you entered in the Insurance company profile a web site a Go To WEB Site button is displayed permitting the user to enter if appropriate the claim via the insurance web interface or consult the insurance web site for information (see Insurance Companies and Plans).
If you are not sending the claim electronically or printing the claim ( for example you are entering claim via the insurance carrier web entry screen) you can change the status of the claim from created to submitted manually, by editing the claim. By placing the claim to a submitted status it will appear in the Insurance AR.
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Create an Automated Claim
To create an automated claim follow the same process as described above in Create a Claim manually. The difference is that if you have eligibility rules and billing rules activated Filopto will use the values calculated during line item data entry to determine the pricing for the claim and complete the claim using all information contained in the Insurance, Inventory, and Patient files. If all field are properly completed the claim should be fully generated. if you have missing fields the claim can be refused due to the missing information. You can also edit the generated claim by selecting the Claim for edit.
Re-Submit a Claim
Filopto allows for the re-submitting of a corrected claim. You can make the adjustment necessary to the invoice or insurance record and then select the Prepare and Update button to update the content of a claim. Only claims that do not have a status of Voided, Submitted, Resubmitted, Payment Received, Transfer to Another Claim, Write Off, Closed or Sent to Collections can be updated.
Change Insurance Policy for a Claim
The Remove Insurance Policy button permits a user to first remove the default patient insurance plan from a claim to be created and then select another insurance policy for the claim to be created. This flexibility is beneficial when for example, a user has a medical and vision plan and at one time you must use the vision plan and at another time you must use the medical plan. This can also be done prior to a claim being generated by simply selecting different insurance policy.
