Claims Center Walkthrough

Claims Center Walkthrough

STEP 1: Adding providers to the Claims Center

Navigate to Settings from the main menu then click Claims Center. 


Go to Providers & Payers tab and click on the Add Provider and/or Create Organization button(s).


Add Provider - A pop-up box will then appear where you can select from the list of professionals in your account. Upon selecting a provider from the dropdown, the system will pre-populate any fields that have already been configured within the Staff & Users or Invoice Contact Details settings. Otherwise, the following fields are required to add the provider: 
Provider Information
  1. First Name
  2. Last Name
  3. NPI --> This will be the professional's individual NPI (not the NPI-2)
  4. Tax ID & Tax ID Type (SSN or EIN)
Practice Information
  1. Practice Name
  2. Phone 
  3. Address
Once the information has been entered in the required fields listed above, click the Add Provider button. 

Create Organization - A pop-up box will then appear and you can complete the following required fields: 
  1. Organization Name
  2. NPI
  3. Tax ID & Tax ID Type (SSN or EIN)

STEP 2: Managing Provider Settings (Rendering Provider, Facility, and Billing Provider)

Once the provider has been added, click on Edit Provider next to the provider's name. 

You'll be taken to that specific provider's settings, where you can edit information regarding the Rendering Provider, Facility and Billing Provider.
  1. Rendering Provider (Box 24 J on Claim 1500 Form)
            Manual - You'll need to input all the necessary details of the provider.
            Supervisor of session's professional - The details of the supervisor will automatically be included. 
  1. Facility (Box 32 & 32a on Claim 1500 Form)
            Manual - You'll need to input all the necessary details of the facility.
            None - There is no facility
Info
We recommend setting the facility to "None" unless you are submitting institutional claims. 
  1. Billing Provider (Box 33 & 33b on Claim 1500 Form)
            Manual - You'll need to input all the necessary details. 

Once you're done making the desired adjustments, you can click Save Changes. 

STEP 3: Add Payers for In-Network Insurance

After saving the changes to the provider details, you can click the "Providers" button to navigate back to the full list of providers. 

Next, you'll click on manage payers next to the desired provider


To add payers to your organization, select manage payers next to the desired organization.

To add a payer, click on the Add Payer button to search the list of all payers within the ClaimMD network. You will want to select the payer that has the correct PAYER ID, which will be displayed as subscript next to the name (e.g., Cox Health Plans 00019)
Notes
If you are unable to find the payer within the list based on the name, we recommend searching based on the Payer ID. 
If you do not have the payer ID, you can view/search the Claim.MD Payer List
Once you've added the correct payer, you will want to click on the "Enrollment" button under 1500 Claims, ERA, and Eligibility. If enrollment for any of those functions is required, ClaimMD will provide the directions for submitting the enrollment.
Alert
IMPORTANT
It is essential that providers are already credentialed with their payers before enrolling in Claim.MD. 


Info
What does "Enrollment" mean? 

After adding providers, the next step is to complete Electronic Data Interchange (EDI) enrollment for each billing provider with every payer that will receive the provider's claims, and/or will return Electronic Remittance Advice (ERA) and Eligibility information to the provider.
  1. No Enrollment Required
    1. If the 1500 Claims column states No Enrollment Required, then no further action is required for enrollment. Claims can be submitted to payers right away!
  2. Auto-Enroll
    1. For Electronic Remittance Advice (ERA) only, if the payer is designated as "Auto-Enroll" in the ERA column, ERA will be received automatically when claims are sent through Claim.MD.
  3. Enrollment Required
    1. If the 1500 Claims, ERA, or Eligibility column for a payer indicates "Enrollment Required," further steps are necessary before enrolling with that payer.
      1. Paperwork that needs to be submitted
      2. Instructions that need to be followed (such as completing information in payer portals)
  4. Quick-Enroll 
    1. If a payer ERA or Eligibility column states Quick Enroll, then this means that the payer has prior authorization for accepting and receiving ERA and Eligibility data with Claim.MD.
    2. Note that the Quick Enroll method is only available for ERA and Eligibility, not for 1500 Claims. 
    3. If a payer's Eligibility is enrolled via Quick Enroll method, the ability to look up eligibility information is available within 24 to 48 hours.
  5. Not Available 
    1. If a 1500 Claims, ERA, or Eligibility column displays "Not Available", this means that this function cannot be enrolled for electronic transmission with that payer.

STEP 4:  Entering Plans for Clients & Checkong Eligibility

Go to the desired client's profile and click on the Claim Center tab on the left-hand side. You'll then click Add Insurance Plan. 

A pop-up box will appear that requires you to select a professional and payer. The items available in the professionals and payers dropdown lists will correspond to that which were entered for each specific professional in the Providers & Payers settings area of the global Claims Center. 

Notes
You will then need to enter the following for the insured's information:
  1. ID Number 
    1. Member ID / Policy ID
  2. Policy Group or FECA Number
    1. If no group number or policy group is listed on the ID card, you can leave this field blank.
  3. Relationship to Subscriber
    1. This refers to the insured's relationship to the primary subscriber. The two options are "Self" or "Dependent." Dependent should be chosen if the insured party is a dependent of the primary subscriber (e.g., child, spouse, etc.)
  4. First Name of Subscriber
    1. Legal first name (no nicknames or chosen names can be used here)
  5. Last Name of Subscriber
  6. Date of Birth of Subscriber
    1. If you've selected "Self" for the relationship and you've entered this into the client's overview tab, this will auto-populate for you.
    2. If the insured party is a "Dependent" on the plan, then you will need the DOB for the primary subscriber. 
  7. Gender 
    1. You can leave this as Unknown or adjust to the legal sex (Male / Female)
  8. Address
    1. If you've selected "Self" for the relationship and you've entered this into the client's Contact Info tab, this will auto-populate for you.
    2. If the insured party is a "Dependent" on the plan, then you will need the address for the primary subscriber.
  9. COPAY TYPE
    1. Fixed
      1. The client will be charged per service with a fixed amount based on the Copay Value you entered
        1. e.g., if the copay type is FIXED and you put the copay value to 10, then the client will be charged a copay of $10 per service
    2. Percentage  (sometimes referred to as "Co-Insurance")
      1. The client will be charged the specified percentage based on the service fee of the appointment.
        1. e.g. if the copay type is PERCENTAGE and you put the copay value to 10, then the client will be charged a copay of 10% of the service amount
  10. EFFECTIVE DATE
    1. This will be the date that the system will begin creating pending claims based on appointments you've scheduled within MBP.
      1. For example: 
        1. If you had an appointment with the client on 03/01/2024 and you are entering their plan information into the system on 03/05/2024, you will need to backdate the effective date to before the first appointment (03/01/2024) in order for a claim to be generated. 

Once done, you can now select the Actions dropdown. Then, click Eligibility.



After clicking on Eligibility, it will display the Insurance Details, including information about the Insured Person and their Benefits.

STEP 5: You're ready to start submitting claims! 

Claims will be automatically generated starting from the effective date you set. Services per session will only be reflected if the billing amount is a minimum of $10.



If there are warnings in the claim's Status column, click the warning sign to view the information that is still needed.

Alert
Here are some of the warnings you might encounter:
- Location code is required.
- Must have a session note.
- Session must have a at least 1 service.
- 1 service(s) of the session has no code.
- Professional must have signature on file.
- Must have at least one diagnosis item.
- Client must have an address on file.
- Client must have a date of birth on file.
Once all the warnings are cleared, you can now proceed to submit your claims by clicking on "Actions" and then File Claim. 


A pop-up box will appear for the File Claim confirmation that says the Appointment Date and Client Name and then click YES to confirm.
Idea
If you'd like to preview the 1500 form before you file the claim, simply click "View 1500 Form." 
Warning
If an error occurs, click on the error icon to see what needs to be corrected. Then, select File Claim to return the claim to the Pending tab. Once the claim is Pending, you can make any necessary changes to the appointment from the calendar. To resubmit the claim again, click File Claim. 
Notes
Once a claim has successfully been filed through the Clearinghouse, the status for that claim will change to Processing

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