The Claim Manager is located in the Managers ability inside the Claim Manager node in the sidebar.
- New Claims Manager
- Outstanding Claims Manager
- Paid/Closed Claims Manager
- Batch Claims Node
- Insurance Appeal Node
Many of the elements in the New Claims Manager are also used in the Outstanding and Paid/Closed Claim Managers. We'll review these elements here.
Filters and Other Options
The filtering options, located on the top half of the New Claims window (as well as the Outstanding Claims, Paid/Closed Claims, and Batch Claims windows) behave similarly to the majority of our Reports. These filters control what charges are included that we can generate claims for. These filters include Provider(s), Office(s), and Insurance Company/Companies - by default, all filters are enabled.
The Start Date and End Date refer to the Procedure Date of qualifying charges needing claims created.
When you have configured the filters to locate the eligible charges you're looking for, click the Apply button to generate a list of potential claims that you can generate. It is important to note that clicking Apply does NOT generate claims, only a list of potential claims.
The pop up menus on the right of the window, described below, are used to locate and adjust specific eligible claims by particular criteria:
- All Incident Types Menu: This menu filters by the available Incident Types as listed in the References ability > Incident Types.
- All Forms & Templates: This menu filters by specific paper forms or eClaim templates.
- Change Form/Template: In the New Claim Manager, this menu will allow the user to create the selected Claims using the selected Form or Template. In Outstanding Claims, this will not allow you to adjust claims to use a new template.
Accepts Assignment means that a provider agrees to accept the maximum allowable charges as payment in full, and to write off the difference between the maximum allowable charges and the billed charges.
Timely Filing Limit
The Days Until Overdue column will reflect how close the procedure date of the selected claim is to the timely filing limit. This limit is defined by what is set in the Timely Filing Limit field in References - Insurance Companies > Claims tab.
Claims highlighted in pink are within X number of days of the timely filing limit, as defined in the Preferences - Insurance > Other Tab > Alert For Upcoming Timely Filing Limits.
Claims in red are past the Timely Filing Limit set in the Insurance Company Reference.
Generating the Claims
Once you have all your options set to your needs, clicking the Apply button will display a list of all potential claims that can be generated. From here, you can review each eligible potential claim. The Print column checkboxes will control whether that potential claim will be generated when the Create Claims button is clicked.
Let's review some more user interface elements here.
The Displaying X of X Claims message in the lower left area of the window will display the amount of claims to be created in this particular Batch of claims.
The Batch Name is used to track these claims in the Batch Claims manager node, discussed later in this article. This normally defaults to a date and time stamp.
The Go to Patient button will take you directly to the selected patient's account so that the claim and the patient's account can be investigated.
Selecting a patient or claim will show the charges that are to be included on that individual claim. If an unwanted procedure appears in the preview, check the box next to Remove Procedure and click the Update Claim button to prevent that charge from appearing on that claim.
If there is a mismatch between the Charge Diagnoses and Claim Diagnoses, based on what Diagnosis Code System is selected in Preferences - Coding and for the particular insurance company, the Claim Diagnosis column will indicate that the codes have not been properly mapped. This simply means that the diagnoses currently listed do not link up to MacPractice's list of currently used diagnosis codes. (otherwise referred to as being "codified").
You can click the Map Diagnosis button to navigate to the patient's charge in the ledger. You can use the code picker by clicking the magnifying glass by any diagnosis code in the Charge Window to map the proper diagnosis code(s).
Once all claims have been reviewed, click the Create Claims button - a popup window will display to confirm the creation of X number of claims. Click the OK button; a generator in the lower left corner will show how many claims are being processed. Upon completion a print window will appear to print paper claims. Electronic claims will be placed in the eClaims ability in either the Ready or Invalid bin for further processing.
The Outstanding Claims manager is structured similarly to the New Claims manager. The filters work identically to the New Claims Manager Filters. The date range will instead search for the procedure date of any claims without a status of Paid/Closed.
In the results section, you can select a particular claim to view what procedures, diagnosis codes, fees, and so on have been submitted. You can reprint any of these claims by checking the box in the Print column and clicking the Reprint Selected button. The claim will not appear twice on a patient's ledger - this will only print another copy of the existing claim, and will only work for paper claims.
Click the Go to Patient button to navigate to the patient's account.
Click the View In Ledger button to go to the patient's ledger and highlight the selected claim.
The date range will reflect the procedure date for which claims were created. Select to view Primary and/or Secondary Claims, Paper Claims and/or eClaims, the Incident Type, and the Form/Template. Click the Apply button to search for paid/closed claims.
You can reprint any of these claims by checking the box in the Print column and clicking the Reprint Selected button. The claim will not appear twice on a patient's ledger - this will only print another copy of the existing claim, and will only work for paper claims.
You can click the Go to Patient button to navigate to the patient's account, if you need to review the patient's details.
If you just want to take a look at the claim in the ledger, click the View In Ledger button to go to the patient's ledger and highlight the selected claim.
For the Insurance Appeal to function properly the following must be in place:
- The provider must participate with the insurance company.
- Either Insurance Estimating must be set up OR
Allowed Amounts must be set up for the Insurance Company.
- You must check "Enable Insurance Appeal" in Preferences.
Setting up Insurance Estimating
If Insurance Estimating is set up with Allowed Amounts saved to the plan, MacPractice will automatically warn a user to appeal a charge. More information on configuring Insurance Estimation can be found in the Insurance Estimating documentation.
Setting up Allowed Amounts Without Estimating
Insurance Estimating does not necessarily have to be enabled to have allowed amounts pull into the insurance payment window. For the appeal to be triggered the following conditions need to be met:
- The patient has an insurance plan
- The plan must have allowed amounts set up in the Procedures tab
- The provider must be set to participate with the plan in the Participate tab
With the Plan Name created and selected, add procedure codes to the Procedures tab. For the first time setting up allowed amounts click the Add From Fee Schedule button, which will bring up a window of existing fee schedules to select from. Select the fee schedule, click the OK button, and all the codes in the selected fee schedule will be added to the plan. After adding the codes, manually select each one and change the fee amount to the allowed amount. Allowed amounts are established between the insurance company and your office; questions about allowed amounts should be directed towards that insurance company.
There is no Database Utility that will enter all the allowed amounts automatically - each insurance company has different requirements for different codes. However, allowed amounts can be copied into other insurance plans (either under the same company or in another insurance company) by going to your Updated Procedures drop down menu and selecting Copy to Other Plan. This feature allows for minor adjustments to be made to existing allowed amounts rather than starting from scratch.
After all the allowed amounts have been adjusted, set this plan in patients' accounts and start using these allowed amounts when receiving insurance payments. To set a plan, go to the Patients ability, select the Primary tab (or Secondary, if applicable) and select the Plan popup menu in the Insurance table.
Enabling Insurance Appeal
Close the Preference window to save the setting.
After the payment is saved, go to the Managers ability > Claims Manager > Insurance Appeal. A list of all patients with an insurance payment and selected to appeal the payment.
Selecting a patient's name from the list will display details about the appeal, such as when the claim was created, when payment was received, how much the payment was for, and so on. This information can be used to follow up with the insurance company in the manner specified by the carrier.