Managing claims is a critical component of the billing workflow. It enables you to review and correct claim information, resubmit rejected or denied claims, or designate a claim as Bill Patient Only when appropriate. These actions help ensure timely reimbursement and minimize payment delays.

For example, if a claim has been rejected or denied, you must manage the claim after making the necessary corrections in order to resubmit it to the payer. If a claim was created in error and should instead be billed directly to the patient, you will also need to manage the claim to select the Bill Patient Only option and redirect the balance accordingly.

Create a new claim for resubmission 

Creating a new claim for resubmission is a simple and efficient process that can be done directly from the Manage Claims screen. For example, if a claim has been rejected or denied and edits were made in the Professional Encounter screen, Patient Case, or Patient Profile, you will need to create a new claim to resubmit it.

When resubmitting claims rejected due to the Rendering Provider's NPI number, updating the NPI on the Rendering Provider screen (under Utilities) will automatically update the claim form. You can then resubmit the claim directly from the Rejected tab, no need to manually manage the claim. Click here to learn more!

Once the necessary edits are complete, click Manage Claims on the Professional Encounter screen.  

On the Manage Claim screen, in the Payer(s) section check the box next to the Payer. 

If you need to suppress previous payment information on a claim, select the appropriate option from the drop-down menu. Each option removes specific prior payment data from the claim file, depending on what needs to be excluded. 

Available options include:

1. Insurance Payment(s) (Loop 2320, Total)

Use this option to suppress the total insurance paid amount for all insurance payers associated with this encounter. When selected, a list of associated payers will appear. You may deselect specific payers to prevent their payment amounts from being included on the claim or transmitted in the EDI file.

This allows you to exclude payment information for certain payers while retaining others, if applicable. 

For example, if the primary payer’s total payment amount was overstated at the claim level but the individual line payments are correct, you would suppress only the Loop 2320 total.

2. Patient Payment(s) (Loop 2320, Total)

Use this option to suppress the total previous patient payment amount for this encounter.

For example, if a copay was accidentally recorded and transmitted with the claim but was never actually collected, you would suppress the Loop 2320 patient payment total.

3. Insurance Payment(s) (Loop 2320 & 2430 – Total and Line Item)

Use this option to suppress both the total insurance paid amount, line-item payment amounts, and adjudication information for all insurance payers associated with this encounter. When selected, a list of associated payers will appear. You may deselect specific payers to prevent their payment amounts from being included on the claim or transmitted in the EDI file.

This allows you to exclude payment information for certain payers while retaining others, if applicable.

For example, if the claim was processed under the wrong payer and all payment amounts (both total and line-level) were applied incorrectly, you would suppress payment data in both Loops 2320 and 2430.

4. Insurance and Patient Payment(s) (Loop 2320, Total)

Use this option to suppress the total paid amount for all payers, including patient payments, associated with this encounter. When selected, a list of associated payers will appear. You may deselect specific payers to prevent their payment amounts from being included on the claim or transmitted in the EDI file.

This allows you to exclude payment information for certain payers while retaining others, if applicable. 

For example, if the claim-level totals for both insurance and patient payments were combined incorrectly or miscalculated, you would suppress the Loop 2320 totals for both.

5. Insurance and Patient Payment(s) (Loop 2320 & 2430 – Total and Line Item)

Use this option to suppress the total paid amount, line-item payment amounts, and adjudication information for all payers, including patient payments, associated with this encounter. When selected, a list of associated payers will appear. You may deselect specific payers to prevent their payment amounts from being included on the claim or transmitted in the EDI file.

This allows you to exclude payment information for certain payers while retaining others, if applicable. 

For example, if the entire payment history was entered in error, such as payments applied to the wrong encounter, you would remove all insurance and patient payment data from both Loops 2320 and 2430 before resubmitting.

Click Create Claim.

On the Create Claim screen, you can manage the claim details before resubmission. Deselect any CPT codes that do not need to be resubmitted, select the appropriate resubmission code, and edit or remove the original reference number if necessary. To exclude a CPT code from resubmission, simply click the checkbox next to it.

Select the appropriate Resubmission Code from the dropdown menu. This code indicates the reason for resubmitting the claim and ensures that the payer correctly identifies it as a corrected or replacement claim. 

For example;

• If the claim is Sent Out and it’s a medicare claim, resubmission code 7 will not be an option it’ll automatically default to resubmission code 1.
• If the claim is Sent Out and it’s not a medicare claim, resubmission codes 1 and 2 will not be an option, it’ll automatically default to resubmission code 7.
• If the claim status is Rejected and not a medicare claim, resubmission code 7 will not be an option it’ll automatically default to resubmission code 1.
• If the claim status is Rejected and is not a Medicare claim we check the claimstatusentityidentifer code value as below:
  • ClaimStatusEntityIdentifierCode is “AY” - this is a field received from the clearinghouse (ClearingHouse - Claim Status Entity Identifier related to 277CA). The resubmission code is set to “1”.
  • ClaimStatusEntityIdentifierCode is “PR” - Resubmission code is set to 1.
• In all other cases, we default it to “1”. 

Enter the Original Reference Number in the Original Ref. No field. 

To include Claim Notes in Box 19, choose the claim note type from the drop-down menu and then input the relevant details in the box on the right side. 

Click Send Claim. 

A confirmation popup will appear stating that a claim already exists for the selected payer and asking if you want to cancel the existing claim and create a new one. Click Yes to proceed. 

The system will then automatically scrub the claim for errors. If correction are needed,  the encounter will be moved to the Corrections Required tab. If no corrections are required the claim will be sent directly to the payer or electronically or dropped to print depending on the payer’s claim filing method selected. Click here to learn more about claim scrubbing!

To save the claim for future submission, click Save Claim.

A confirmation popup will appear stating that a claim already exists for the selected payer and asking if you want to cancel the existing claim and create a new one. Click Yes to proceed. 

The system will then automatically scrub the claim for errors. If correction are needed,  the encounter will be moved to the Corrections Required tab. You’ll need to make the corrections before the claim can be submitted.

If no corrections are required the claim will move to either Ready to send Elec. Claims or Ready to Print Claims within the Claims tab depending on the payer’s claim filing method selected.  

Bill patient only

If a claim was originally submitted to an insurance payer in error and later determined to be the patient’s responsibility (for example, the patient had no active coverage on the date of service), you would switch the claim to Bill Patient Only.

To begin, click Manage Claims on the Professional Encounter screen.  

On the Manage Claim screen, select the SelfPay checkbox, then click the Bill Patient Only option. 

A confirmation pop-up will appear indicating that all payer claims must be in a resolved status before billing the patient only. Click Yes to continue.

Once the update is complete, the Manage Claim screen will display a lock icon, indicating the claim is now set to Bill Patient Only. You will also see an option to Revert from Bill Patient Only if you need to undo the change.

For example, a claim was initially moved to Bill Patient Only because the patient’s insurance appeared inactive on the DOS. Later, the patient provides updated insurance information showing that overage was active at the time of the visit. In this case, you would select Revert from Bill Patient Only to unlock the claim and restore it to the appropriate insurance payer for billing.

Click Close to exit the Manage Claim screen. 

The Professional Encounter screen will display the patient’s name in the Responsible Party field, indicating that the patient is now financially responsible for the balance. The encounter status will also update to ReadyToBill, confirming that the charge is prepared for patient billing. 

Click Cancel to exit the Professional Encounter screen. 

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