For workspaces with the insurance claim module enabled, CMS 1500 claims can be created from billing items for services provided through appointments in Carepatron.
Before creating a claim, ensure that you have done the following:
In this article, we will cover how to:
Note: The insurance claim module is currently only available for workspaces in the United States.
Create a claim from an appointment
One way of creating a claim is through the appointment itself. To do this:
Click on a client appointment.
Click on 'View' to be directed to the billing details.
This view will show any claims related to the appointment and any unclaimed amounts.
Look for the drop-down arrow next to the service amount.
Click '+Add insurance'. If it doesn't appear, it means it has already been encoded. You may edit or remove the self-pay amount by clicking on the amount fields.
Click Save.
In the Unclaimed amount banner, click '+Add claim'.
A new claim will automatically be created, pulling information from the appointment.
The newly created claim will appear on the appointment.
Click on the claim to open the claim view.
Troubleshooting:
If there is no claim on the appointment and no unclaimed amount, ensure that at least one billing item has an insurance amount.
If the Unclaimed amount banner appears but there is no Add claim button, your workspace may not have the insurance claim module enabled.
Create a claim from client billing
Follow the steps below:
Go to Clients.
Select a client.
Go to the Billing tab.
From the main billing panel, select New, then click Claim in the drop-down.
Alternatively, you may also go to Billables, navigate to the appointment, and select the New Claim icon next to the appointment.
Choose the unclaimed items to add to the claim.
Click Create.
Create a claim from the claim list
To do this:
Go to Billing.
Select the Claims tab to open the claim list.
Click New Claim in the header.
Choose the client for whom you want to create a claim.
The client’s unclaimed items will load for selection.
Choose the unclaimed items to add to the claim.
Select Create.
Add items to an existing claim
Go to Billing.
Navigate to the Claims tab.
Open the claim to which you want to add items.
Expand the Diagnosis & Billing Items section.
Click '+Add billing items'
Select the unclaimed items.
Click Add claim.
Note:
If unclaimed items do not appear, go to the client's record and create billables for the appointment.
Billing items are not automatically created for recurring appointments. You have to generate them manually from the appointments.
Complete a US Professional (CMS 1500) Claim Form
Carepatron will attempt to pull relevant information when creating a new claim; however, claims must be reviewed for accuracy and completeness.
When completing the form, make sure to do the following:
1. Review client Information
When creating a claim, client information is pulled automatically.
Adjust this information if necessary within the claim.
2. Add Incident Information
Incident information captures details about the cause of the need for healthcare services.
3. Review the rendering provider
The rendering provider(s) indicate who provided the services on the claim.
These are automatically added based on the appointment staff, but adjustments can be made within the claim.
4. Adding a referring provider
The referring provider is the healthcare professional who referred the client for services.
5. Select the service facility
This is the location where services were provided.
It is pulled from the appointment’s selected location but can be adjusted manually.
6. Selecting a policy for the claim
The Insurance Information section allows selection of the client’s insurance policy for the claim.
Ensure that:
The policy details are correct.
The payer details are accurate.
The services added to the claim correspond with the selected policy.
7. Add billing information
The Billing Information tab describes the billing details required for claim submission.
These must match the billing and tax details used when enrolling with the payer.
The billing profile is selected based on the rendering provider and payer, but can be adjusted if necessary.
8. Add diagnostic and service details
The Diagnosis and Billing Items section outlines the client’s diagnosis and the services provided.
ICD-10 Diagnosis Codes are pulled from diagnostic notes attached to the appointment.
Service Details are created from billing items in the client’s profile.
Place of Service Codes come from the appointment’s location.
Review your checklist
Ensure the Service Lines contain the correct details.
Verify that the Service Description and Coding are accurate.
Check that Diagnosis Codes and Service Line Diagnosis Pointers are correctly linked.
Add any necessary supplementary information or modifiers for services provided.
Confirm that the Amount Paid matches the already paid amount.
Common errors
Using outdated codes.
Improper linking between diagnoses and procedures.
Missing required modifiers.
Mismatched billing details or identifiers with the payer.
Validating claim
A draft claim can be validated for common errors by selecting Validate in the claim header.
The claim will be checked for common errors to ensure completeness before submission.
Submitting an insurance claim electronically
Electronic submission is available for payers that have been imported from our clearinghouse. For all other payers, submission must be handled manually.
To submit an electronic claim:
Open the claim.
Check that the submission method is Electronic.
Click Submit in the claim header.
Carepatron will submit the claim to the clearing house.
Fix any additional validation errors that may be returned.
After a successful submission, the claim will show as Submitted.
Our team will be able to answer any other questions you may have. Just reply via messenger through the Help channel in your workspace.