How-To Guides
Using the Claims Center
Measurement-Based Care — Guide Coming Soon!
Using the Claims Center
Go to “Financials > Claim Center” via your top menu bar.
Each claim is processed via the following 7 steps:
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Open – the note is ready for billing review, and is still open for billing changes (no claim has yet been created)
Created – the claim has been created and is ready to be submitted
Pending – the claim has been submitted, and is pending within the insurer’s adjudication system
Repairable – the insurance company rejected the claim with an error, and the claim needs to be repaired and resubmitted
Issue – your billing team has identified an issue with the claim that requires a call to resolve
Finalizable – a payment or ERA has been received from the insurance company, or the insurance balance of the claim is $0.00, the claim is ready to be reviewed for correct payment amounts then finalized
Finalized — all insurance payments are received as expected
Tip: You may hover over each of the steps in the claims pipeline to see a description within the EHR as well.Open. There are two ways to create a claim: directly from the note (for a provider with billing permissions), or by reviewing all open notes (for the billing team).
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The Open page of the Claims center allows you to view a list of all of the latter, and go through each note one by one by clicking “Review Open Notes” at the top right.
For each note, please review the billing section of a note to verify that the CPT codes and Place of Service (POS) is as expected.
Then click “Create Claim”.
If there are no rates, or the charges total up to zero, a claim will not be created, as your clinic is not expecting to receive any payments. The blue action button will then instead read “Finalize” to finalize the billing immediately.
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If this is in error, or if any rates are added retrospectively, you may at any time before claim submission re-open/unfinalize the note to re-generate the charges, and then repeat the previous step.
If a claim was already generated, first click “View Claim”, then “Actions > Re-open Note”:
If no claim was generated, first click “Unfinalize”:
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Created. To submit a claim, simply click “Submit to Insurers” and the claim will be sent to insurers at midnight on the same day.
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The claim is already auto-populated with information from the note and the patient’s registration. Please review for correctness before submitting.
You may make any edits until the submission at midnight. To cancel the submission, you may use “Actions > Re-open Note”.
If a payer was not selected in the patient registration, you will have to select the payer before submitting. For other tweaks, until the claim is submitted, you may also edit the registration directly, and the information on the claim will receive the changes.
Pending. The claim is being processed in the insurer’s adjudication system, and is pending any payments or Electronic Remittance Advice (ERAs), also known as Explanation of Benefits (EOBs), from the insurance company.
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A claim is pending until a payment is received. When a payment is received, the claim will move to the Finalizable page.
To record the ERA and insurance’s payment amount into the EHR, click “Record Payment…” and apply the claim to the appropriate charges:
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You may filter the charges based on claim number, patient name, date of service, etc.
Where do I find insurance payments (ERAs)?
You can receive ERAs automatically uploaded to your payments and matched to claims by enrolling in ERAs on the 'Manage Billing > E-Payers' page.
Repairable. If a claim appears on the Repairable step, there was an issue with the claim, such as a box that was filled out wrongly, or any formatting issues. The claim must be corrected and then resubmitted to the insurance company.
First, you will need to create a resubmission and correct the claim, one by one for each of the claims on this list. The claims with IDs in red on the left have not yet been fixed.
To create the resubmission, either click the red ID, or hover over the denial reasons on the right-most column and click “Create Resubmission”.
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This will allow you to override the claim and make changes to fix any of the denial reasons given.
Particularly note Box 22 on the claim form: if the payer assigned a reference number for the rejected claim, you should select “7 - Replacement of Prior Claim” when resubmitting.
Note that the error messages given by the insurance company typically appear cryptic and use strange codes such as “2010AA-N403”. This corresponds to the more advanced EDI view mode for a claim. For example, the given error:
2010AA-N403: Value of element N403 is incorrect. Expected value for ZIP Code is 9 digits. Segment N4 is defined in the guideline at position 0300. Invalid data: 23123 (HIPAA)
Indicates that the zip code field (element 03. Zip Code) for the billing provider (segment 2010AA-N4) was incorrect, since a 9-digit zip code was given instead of a 9-digit zip code.
You may see the EDI mode for a claim by clicking “EDI” at the top right of the claim and CTRL+F for the given error code.
After the appropriate changes are made and saved, you may click “Resubmit to Insurers” for the repaired claim. The claim is now repaired!
Issue. A claim can be moved to the issue step any time after submission. This can be done via “Actions > Flag Issue”.
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Here, your billing team may record calls to the insurance company or any other actions.
To move the claim out of the Issues page, click “Resolve…”
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To resubmit the claim, move it to the Repairable page. To indicate no further action is required from you, move it to Pending. Otherwise, if the issue has been fully resolved and the claim is fine as it is, move it to Finalizable for a final review and check off.
Finalizable. Now the final step is to review your Finalizable claims and make sure that the insurance actually paid the correct amounts.
To reconcile revenue for each claim and adjust charges where necessary, click “Actions > Adjust Charges”.
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If the insurance company balance is not $0.00, or the charges otherwise don’t match the Electronic Remittance Advice (ERA), you may adjust the charges to match.
Select an adjustment reason to describe why the adjustment was made.
For example, if the insurance did not pay, and your clinic is not appealing the denial, then mark the insurance denial and adjust the charges appropriately:
If the claim has an issue and the payment amount was incorrect, and should be resolved by appealing or calling the insurance company, click “Flag Issue” and describe the problem.
Finalized. The claim is now finalized. Congratulations!
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Resubmitted claims will also be displayed on this page.
If you need to create a secondary claim for the visit, you may click “Create Secondary Claim” to send the claim to another payer. The previous steps will be repeated.
That’s a wrap for the Claims Center. To see this process from a monetary or accounting angle instead, you may also use the Accounting Center, accessed via “Financials > Accounting Center”. This shows you a breakdown of all paid and unpaid charges, payments, and on, in your EHR.