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Ledger - Claim Creation Window

The Claim Creation window is used to enter the details of the claim before sending it to the eClaims ability or printing it out on paper. This window will allow the user to select the correct insurance company and the correct Diagnosis Code System. To access this window, select a charge or multiple charges in the ledger and choose "Create Insurance Claim" from the Print menu.

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Claim Creation Options

At the top of the Claim Creation window, you will have a few options to choose from:

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Print Statement Checkbox and Form

The Print Statement checkbox in the Claim Creation window allows you to generate both documents at the same time. While most offices choose to print statements in bulk through the Statement Manager, or individually using the Print Menu in the ledger, this option has some convenient features.

If your office generates statements at the time of filing the claim, this saves the extra steps used when printing individually. Other offices use this to print a one time statement for a patient using a different statement form, without needing to change any default settings.

For example: Your office uses the 4 column statement for regular bills, but you need a statement with code and diagnosis information for the patient's flex spending card. Instead of changing the entire office's preferences from the default 4 column form, you would simply print through this menu.

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Create Insurance Claim Checkbox

These boxes will be checked by default when you are using the Claim Creation window. However, you may disable them on a one-time basis if you are simply needing to print a statement and generate the patient's Clinical Summary.

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Export Clinical Summary to the Patient Portal Checkbox

This box is used if your office needs to export summaries for a Medicare Incentive or if you use the Portal and want this information relayed to the patient every time a claim is created. When checked, MacPractice will open a new dialogue box allowing you to choose what details to send. 

If you are not participating in any program requiring the summaries and your office does not need these, you can disable this feature. Uncheck the "Export Clinical Summary" box; this setting is remembered per computer. Once unchecked, it will remain that way on this computer until changed back. 

There are several other ways to print or export the Clinical Summary

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Claim Table

Within the Claim Creation Table, you can make additional adjustments to the claim to insure it is properly generated before it is printed or electronically submitted to the clearinghouse. 

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Create Claim Checkbox

These boxes will be checked by default when you are using the Claim Creation window. However, you may disable them on a one-time basis if you are simply needing to print a statement and generate the patient's Clinical Summary. 

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Insurance Carrier and Other Insurance

This popup shows which insurance company this particular claim is being sent to. When creating a primary claim, this field will pull in the first insurance listed on the Patient tab. If the patient has secondary insurance, it will display in the Other Insurance popup.

Once the primary claim has been paid and a new claim is created for the secondary insurance, the order of insurances here will switch.

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Form/Template

This box controls which paper form or eClaim template will be used to generate the claim. You may set up a specific form per insurance company in the Insurance References

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Prior Auth

In order to include a prior authorization number on a claim, select the prior authorization number you wish to include on the claim from the Prior Auth pop-up menu. The number of remaining visits will be listed in parenthesis after the authorization number.

This information will pull into Box 23 on the CMS Claim Form and Box 2 on the ADA Claim Form

If "None" is your only option, visit our THIS article for more information on creating a new Prior Authorization.

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Accept Assignment Checkboxes

The Accept column in the claim creation table can be checked or unchecked to add or remove the Accept Assignment indicator on the fly. When the Accept box is checked or unchecked, the status will be mirrored by the 'Accept Assignment' checkbox in the lower-left corner of the claim creation window. Likewise, if you change the status of the checkbox in the lower-left corner of the window, the 'Accept' box in the claim creation table will check or uncheck to reflect that status.

For more information visit our "How do I Indicate Accept Assignment in MacPractice?" article. If you are unsure what Accept Assignment means, take a look at our "What is the Purpose of Accept Assignment for Claims?" article. 

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Secondary Checkbox

This box indicates that this is a secondary insurance claim. When the primary payment has been entered or the primary claim has been closed, the secondary claim can be created.

MacPractice will change the order of insurances to show the correct insurance as the carrier for this claim and automatically check the secondary checkbox. If this is not a secondary claim, you can manually uncheck it or change the order of the carriers.

For more information on creating Secondary Claims, visit our How To article.

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Diagnosis Code System

The diagnosis code system that is used will come from the Insurance Companies Reference > Claims tab. At this point, most carriers use ICD-10; however, if a particular insurance still wants ICD-9 or you use your own custom codes, you could change this on a per carrier basis.

If the reference is set to "Use Coding Preference Default", then it will base this information in the MacPractice menu > Preferences > Coding > Billing Diagnosis option

You can manually override this per claim by updating the code system in this menu on the Claim Creation Window.

If the coding system used on this claim does not match the codes on the charges, MacPractice will indicate that the diagnosis codes are Not Mapped and will require you to select the correct codes prior to creating the claim. For more information, visit our Claim Creation Code Mapping article. 

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Ins. Paid and Pat. Paid

These fields display the amounts of payments applied to the charges. It will always display the credits on the claim creation window, regardless of whether you choose to have the payments display on the claims themselves.

This information can show up in Box 29 on the CMS Claim form based on what you have selected in the Insurance Companies Reference > Claims tab.

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Split Reason

Most offices prefer to have all of the patient's procedures on a single claim being filed. However, claims will sometimes need to be split into multiple claims.

How can I tell if my claim is being split?
When you generate a claim, you're taken to the claim creation window. You can tell if there are multiple claims that will be generated by the line listed for each claim. You can also see "x claims will be created" on the top left of the claim creation table as shown in the below screenshot.
If you scroll to the right, There is a column far to the right, "Split Reason".

Reasons for Split Claims
There are several reasons why charges would split into multiple claims. If any of the following information differs between charges, separate claims will be generated.

  • Different Insurance: This would occur if the patient has charges from January and insurance that was active up until January 31. They also have a procedure from February and a new insurance on their account active February 1. While you select both charges, they will split into two claims. 
  • Different Provider ID: This can happen when you have different a provider listed in each charge window.
    • This can be resolved by selecting the same provider under the "Provider Shown on Claim" menu of the charge window.
  • Different Office ID: This will occur if you have different Offices listed in the charge window for each procedure listed on the claim.
    • To fix this, simply go back to the ledger open each charge listed on the claim, and make sure the Offices match.
  • Different Referral ID: This will happen when you have different referrals selected on each charge listed on the claim.
  • Different Demonstration Code: This split reason will happen when you have several codes on your claim with different Demonstration Codes
    • To fix this, be sure that the demonstration codes are correct. If not, update them and create a new claim. If these codes are correct and are required by the payer, it is best to keep the claim split.
  • Different Facility ID: This will happen when you have several procedures on the claim with different Facilities listed. 
    • This can be resolved by removing the other facilities, or making sure all of the facilities match between the procedures. You can also go to the MacPractice menu > Preferences > Forms > Check "Create as Few Claims as Possible".
  • Different Lab ID: This can occur when there are different labs listed on each procedure listed on the claim.
    • This can be fixed by removing or editing the Lab listed in the charge window. Or you can go to the MacPractice menu > Preferences > Localization > Check "Do Not Split Claims for Different Labs".
  • Diagnosis code count greater than 12:  This will happen when you have more than 12 diagnosis codes listed in the charge window for the procedures on the claim.
  • Maximum Proc Count: If a claim has more procedure codes than there are lines available in a claim form, the claim will be split in order to accommodate all procedure codes.
    • There is not a way to fix this one, if you need all of the selected procedure codes sent out on a claim, it would be best to do so on multiple claims. 

Preferences that control Claim Splitting

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Resubmission Code and Resubmission Reference

MacPractice's default claim form does not have this field enabled. However, we have created a new form for offices who need to add a resubmission code/reference in Box 22 of the CMS Claim Form. The form will pull from these two text fields, otherwise it will be left blank. 

For the new forms, click these links:

Click here for the NPI and Legacy CMS 1500 form.

Click here for the Only NPI CMS 1500 form.

Note: If you have difficulty clicking the above links, right click the link and click "Copy link". Then paste the link into a web browser.

The downloaded file should be in an .fgen format, which can only be used by MacPractice. To install the form, simply double click on it, then follow the prompt in MacPractice to import.

If no such prompt appears, you can also navigate to the References Ability, select the Forms node, click the Green Plus button in the side to create a new record, and then click the "Import..." button. You'll need to name the Form before importing when doing it this way.

You may choose to make this your default form or just use it on a case by case basis.

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Claim Detail Tab

This tab will give a summary of the information selected above in greater detail. The name and address of the insurance company selected above is based on the information within the Insurance Reference.

If the patient does not have an Insurance Plan selected in the Primary/Secondary tabs, The insurance company address will pull from the Company Info tab. 

If there is a plan selected for this patient, the address of the specific plan will pull from the Plan tab > Demographic sub-tab.

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Procedures Tab

This tab is great to quickly preview all of the procedures and procedure information before it is printed on the claim.

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Date

This column will reflect the procedure date of the procedure listed in the row. The date will pull directly from the Procedure Date field in the charge window.

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Code

This column will list the procedure codes being pulled onto the claim. This will be based on the selection you made in the ledger before opening the claim creation window.

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Fee

Each fee amount will pull into this column. This information comes from the Fee Schedule Reference, unless overwritten in the charge window on a per-charge basis. If this is a unit based fee, the total fee is what will display on the claim.

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Description

This column will show the description of the procedure selected. The description pulls from the Fee Schedule Reference, unless overwritten in the new charge window.

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Charge Diagnoses

This displays the diagnosis code that was listed in the charge window for the procedures. Typically it will display an ICD-10 code; however, if it has an older code such as an ICD-9 code, then you will be prompted to map it to the code system that the insurance company accepts.

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Claim Diagnoses

This is the diagnosis that will display on the insurance claim that is printed or sent electronically. It is typically an ICD-10 code. If the code is not an acceptable format, then "Not Mapped" will display until the right coding system has been used. 

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Just Print, Don't Save Checkbox

By default, MacPractice will save a PDF of every claim created to the patient's ledger. We recommend keeping this PDF in case the claim needs to be reprinted or viewed in the future. To view the claim, simply double click on the line.

However, you may choose to disable this feature for a claim; for instance, if you are simply printing it for the patient or doing a test print to verify information on it. In the claim creation window, uncheck the box and the claim will generate, but a copy will not be saved. 

If you are choosing not to save PDFs because of space, please consider a database utility that would delete PDFS of claims that have been closed and are past a certain age. 

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Encounter Form Number

If you add an encounter form number to this field, the Encounter Form within the Encounter Tracker can be marked as "Received" directly from the Claim Creation Window.

The Encounter Form Number is listed in the Serial # column within the Encounter Tracker entry line.

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