Claims Detail Screen





 

Button/Parameter Name

Function
New Claim Clicking this button clears all of the information from the Claims Detail screen, and increments the Claim Number counter to the next available Claim Number. It will also prompt you to save changes if you are in the middle of entering a claim when you click here.
Save Changes If editing a claim or creating a new claim, clicking on Save Changes will commit all changes or information about the new claim into the database for storage. To save, all data must be formatted properly.
Form Type This is the type of form being entered. Options include HCFA, UB, DEN, VIS, and OTHER.
Mail Rec Date This is the date when the form was recieved by mail at the TPA.
Employee SSN This is the nine digit number containing the Social Security Number or scrambled identifier of the employee.
P Suffix Sometimes called the SSN Suffix or the Patient Suffix. (01- Employee, 02- Employee's Spouse, 03- First Dependent Child, 04- Second Dependent child etc.)
Prov Patient ID This is the patient's identification number at the office of the provider. This is the unique identifier the provider uses to refer to the patient in the provider's patient tracking system.
Provider Tax ID This is the providers tax identification number issued to them by the federal government.
Suffix This is the tax suffix assigned to them either by the network or by the TPA.
Prov Addr# This is one of the provider addresses, for the check to be sent to.
Name Search Used to find a provider in the system. Clicking here will load the Network and Provider screen.
POS POS is the 2 digit predefined ANSI Standard Place of Service.
DOS Earliest Earliest Date of Service is the first time the patient was serviced.
DOS Latest Latest Date of Service is the most recent time the patient was serviced associated with the same claim. If there was only one date of service, the Earliest and Latest DOS should then be equal.
Admission Date If the patient was hospitalized, the admission date is the date the patient was admitted to the hospital. Otherwise, it is insignificant, and should be entered as the Earliest DOS.
Total Charges This is the total amount of money the provider requires to pay for the service provided.
Diagnosis Type Blanks 1-4 These blanks are used to enter the ICD 9 codes representing the doctors diagnosis of the patient's disease or illness. Usually only one code is needed, but sometimes, more are required.
CPT 1-6 Up to six CPT/HCPCS codes can be stored in this area. For claims with more than six CPT codes or codes with modifiers, use the "Det" screen (which will store up to 20 CPT codes, along with modifiers).
Units 1-6 Enter the unit count for each corresponding code here.
Hospital Procedures Up to four ICD-9 V3 codes can be stored here, where required.
Det Clicking this button will open up the Det screen panel on the Claims Detail window. This allows you to enter up to 20 CPT codes, and enter specific Rx, Modifier, and units for each.


 

Button/Parameter Name

Function
1-5 Button When this button is not active, it means that the first five benefit line codes associated with the claim, are currently being displayed below. When active, clicking here will move the first five associated benefit line codes into the blanks below for display, modification and viewing.
6-10 Button When this button is not active, it means that the second five benefit line codes associated with the claim, are currently being displayed below. When active, clicking here will move the second five associated benefit line codes into the blanks below for display, modification and viewing.
Employee This is to enter in the amount to be paid to the employee if any.
Provider Blank This is the amount to be paid to the provider.
Other Ins. Pay This is the amount that other insurance companies pay on the claim.
Third Party This is the amount that other liable parties pay on the claim.
Claim Status This selects the current status of the form. If the claim status is DONE, no date on the form may be modified.
Benefit (1-5) This lists the Benefit Line Code of the claim. Only potentially applicable Benefit Line Codes will appear as options here, and is determined by which CPT codes were entered.
Billed Amount (1-5) This is the total amount the provider is requesting for his services.
Allowed (1-5) This is the total amount the provider may receive for the service provided.
Code (1-5) This code represents the explanation why the provider will only receive the allowed amount and will not receive the billed amount.
V (1-5) This refers to the number of visits.
D (1-5) This refers to the number of days.
Top Row of Checkboxes These will flag the claim, so that a Pend Letters will be sent to the employee regarding the claim, depending on which boxes are checked.
Bottom Row of Checkboxes These will flag the claim, so that a letter will be sent to the provider notifying them that the claim has been put in pend status.
AccDet This option's associated pend letter states more information regarding accident, injury or illness is required to process the claim.
MedRec This option's associated pend letter is a general medical release form, requesting permission for others to release medical information regarding the claim to the TPA.
OI This option's associated pend letter requests information regarding other insurance carriers if any.
DetBill This option's associated pend letter states the a more detailed bill of services provided is provided before a claim can be processed.
Stud This option's associated pend letter requests a verification that the patient is a student.
PX This option's associated pend letter contains a medical release form, requesting information about the patient's pre-existing condition, that can influence the pended claim.
TPL This option's associated pend letter is a an agreement for the patient to reimburse the TPA for any money paid by third party liability.
Internal This option when selected, simply pends the claim for internal purposes.
Multi-Line Text Entry Field This displays the message to be printed an the EOB statement. The maximum size of the message is 250 characters.
Suppress Check When the claim is about to go into PROC status, select this will flag this claim's check to be suppressed until further notice.
*Claim Notes Any special notes or messages that need to be associated with the claim, can be entered here.


  The Claims Summary tab closes the Claims Detail screen and opens the Claims Summary screen. 


 

Button Name

Function
EVT This is a speed button to the Event Tracking screen, which will open to all events correlated with the currently selected claim.
ELG This is a speed button to the Enrollment screen, automatically opening to the employee whose claim is currently selected in this screen.
Copy PROV
 This will generate a copy of the original Provider statement in report form (for viewing or printing), for the currently selected claim. The difference between the original and the copy, is that the copy doesn't have a real signature, and says COPY.
Copy EOB
 This will generate a copy of the original Employee Explanation of Benefits statement in report form (for viewing or printing), for the currently selected claim. The difference between the original and the copy, is that the original says VOID and this one says COPY.
RPT This opens the Eligibility Reports window.
LTR This opens the Letters window.
ADM This opens the Administration Tools window.
ELG This opens the Enrollment screen.
CLM This shows that the Claims Entry screen is open.
NWK This opens the Networks and Providers screen.
EVT This opens the Event Tracking screen.
PLN This opens the Plans and Options screen.
GRP This opens the Groups, Locations, and Units screen.


  This button closes the Claims Manager program.