Claim Summary Screen

The Claim Summary screen displays when an individual claim line is clicked. In this screen, actions can be performed on the selected claim only.

CLAIM SUMMARY SCREEN Field Description Claim

Information

The top part of the Claim Summary screen displays all of the information that was included on the claim, i.e., status, balance, last activity date, subscriber number, insurance company, insurance plan, billing and servicing provider, billing provider UPIN and NPI, referring provider, admission date (if applicable), and authorization number (if applicable), provider's tax ID, provider's enrollment status in insurance and the effective date of enrollment. These fields cannot be edited however, the billing provider and the referring provider's insurance number details can be viewed by clicking on the respective provider's name.

Note: A provider's participating status can be one of the following:

• N/A- This indicates that the insurance carrier does not require specific enrollment/credentialing to participate.

• No- This indicates that the provider does not participate with the insurance listed on the claim.

• Yes- This indicates that the provider is enrolled with the insurance and displays the date of effective date.

Rebill As The Rebill As field is users to flag an electronically resubmitted claim (ANSI 837 format) with a code that indicates the claim is a

re-submission. Flagging a resubmitted claim prevents the claim from being denied as a duplicate.

Code Definitions

Notes An activity note can be added to the claim by entering the note in the

"Notes" field and then clicking on the Save button. Adding a note re-starts the claims aging used to determine inactive claims.

CLAIM SUMMARY SCREEN

Rebill To==> When the needed information has been added to and or edited to the claim or the patient's demographic, the Rebill To==> button must be clicked in order to rebill the claim. When a claim is rebilled, it will be placed in the New/Pending column on the Claims Worklist screen and will be transmitted during your next bill run. Before clicking on the Rebill To==> button, verify the form type selected in the "Form Type" field. A form type must be changed before clicking on Rebill To==> button.

Form Type ANSI form types are claims that are electronically transmitted to a payer and paper form types are claims forms that are dropped to paper that must be printed from Optum PM and Physician EMR and then mailed to a payer. The default form type for the insurance plan the claim needs to be sent to is selected in the "Form Type" field. W hen a form type needs to be changed, selected the appropriate form from the "Form Type" list and click on the Rebill To==> button. When ANSI format is changed to paper, Optum PM and Physician EMR ensures the proper information is present on the claim form before releasing the claim to print.

Rebuild Paper Claim

The Rebuild Paper Claim button can be used to print paper claims without Optum PM and Physician EMR verifying the accuracy of the information. The form type selected in the "Form Type" field must be a paper form. W hen the Rebuild Paper Claim button is clicked, the claim displays in a window, right-click on top of it and select 'Print' from the grey pop-up menu. The claim will be removed from Claims Worklist when the Rebuild Paper Claim button is clicked.

View Paper The claim will display in a window when the View Paper claim button is clicked. Clicking on the View Paper button does not remove the claim from the Claims Worklist link.

Edit Clicking on the Edit button on the Claim Summary screen displays the Encounter window from which you can add and/or edit claim information including the location, place of service, Additional Claim Info, referring provider, modifiers, and diagnoses. Dates of service, procedure codes, fees, the insurance company and the amount of the claim may not be edited from this pop-up.

Note

CLAIM SUMMARY SCREEN

Claim Status Every evening, Optum PM and Physician EMR will automatically check the status of every claim on which there is an outstanding balance. A claim is checked for the first time after seven days it is flagged as

"TRANS OPEN". If the claim status continues to remain "In process" the second automated check is performed three days after the first check.

Since a third check is not performed by Optum PM and Physician EMR it is best practice to call the payer and follow up on the claim or manually recheck the claim status. There are particular statuses returned from a payor when a claim's status is checked: 'In Process,' 'Finalized', 'Set to Pay', 'Set to Deny', 'Pending In Review' and 'Not Found'.Each claim will be updated accordingly when the automated batch claim status check is complete. W hen a status of 'Set to Deny', 'Pending in Review' or 'Not Found' is returned during an automated batch claim status check, the claim will be updated and flagged in the Claims Worklist link under the Billing section of the Dashboard.

The Claim Status button on the Claim Summary screen enables manual re-check of claims status without having to wait for the automated process.

Note: Optum PM and Physician EMR does not check any claims moved to the 'Hold' category automatically. However, you can perform a manual claim status check if necessary.

Status The "Status" field can be used to manually change the status of the claim. 'Select' defaults in the "Status" field however, the status can be changed by selecting the appropriate status from the "Status" list, i.e., 'Payer Edits', 'Not Found', 'Claim Status Denial', 'Missing Info', or 'In Review' and then clicking on the Save button. Manually changing the claims status will move the claim to the corresponding column on the Claims W orklist screen.

Save Clicking on the Save button will save an activity note that has been entered in the "Notes" field and/or a claim status that has been selected from the "Status" list.

Inactive The inactive button allows you to manually set an inactive date for one or more claims. When an inactive date is set, you can hover over the Inactive button to view the date. Additionally, Optum PM and Physician EMR adds an entry to the activity log below the Claim Summary each time an inactive date is set for a claim.

Status column

The status column shows the claims current status and all of the status steps the claim has gone through.

Activity Date Logs the date and time of all activity taken on the claim.

CLAIM SUMMARY SCREEN Activity

Notes

Claim errors occur when a claim does not meet specific requirements set by Optum PM and Physician EMR and/or payers. Errors display under the Activity Notes section of the Claim Summary screen as a mnemonic code along with the error description. Error descriptions direct you as to what pieces of claim information needs to be fixed before the claim can be successfully transmitted to a payer.

Example: "BPINNO - Billing Provider/Insurance Number is missing for this particular Billing Provider/Insurance combination" instead of BPINNO only.

Key By clicking on the Key link, a list of all the possible system note codes and their corresponding message will display. This key can be used to decipher a code that you do not understand.

Link The Acknowledgement and the Report electronically received into Optum PM and Physician EMR from a payer that included the claim will be accessible from the Claim Summary screen. The Acknowledgement report can be viewed by clicking on the ANSI 837 link and the Report can be viewed by clicking on the Report link. The Report shows all the claims that were transmitted in the same claim batch as the current claim's summary you are viewing.

Operator Logs the operator who performed each action that has been taken on a claim.

Claim Batch ID

This shows the claim batch identification number.

Procedures Each procedure line included on the claim will display in the lower part of the Claim Summary screen. Under each procedure line will be a record of all the financial transactions linked to each procedure.

Payment The Payments screen displays when the Payment link is clicked from which a financial transaction, i.e., payment, adjustment, or transfer, for the respective procedure line can be entered.

Separate Claim

When multiple procedure codes appear on one claim, those procedures can be separated to different claims by clicking on the Separate Claim link.