Claims Generator

(Topic Last Updated On: 05/01/2018)

Accounting > Third Party Billing > Claims Generator

The Claims Generator screen is accessed from the Third Party Billing sub-menu, found on the Accounting menu. This screen is used to view, generate, and/or delete new and existing billing claims for reporting purposes, generating Billing Export EDI files, and/or submitting billing claims to Third Party Payers. This screen is also used to reset claims from a 'Submitted' status to an 'UnSubmitted' status. This screen relies heavily on the required selections made in the 'Service Criteria' section, allowing users to view claims that have been 'Submitted' vs. 'UnSubmitted'. Charge information for each claim, is displayed on the grid. This functionality allows users to edit one or more Service Lines of each claim. Claims generated on this screen are generally exported into EDI files for submission to Clearinghouses and/or Third Party Payers using the Billing Export function, found on the File menu. However, some facilities use this screen to simply generate claims for data and reporting purposes in conjunction with other Third Party Billing software. A basic understanding of Methasoft's advanced third-party billing features is helpful when using this screen. Click Here to view videos on Methasoft Accounting and Billing.

Field Descriptions

From Date

This field contains a calendar date selection menu used for entering or selecting the first Date of Service (DOS) for Service Lines included in the Claim.

To Date

This field contains a calendar date selection menu used for entering or selecting the last Date of Service (DOS) for Service Lines included in the Claim.

Patient ID

This field is used to enter a patient ID when searching for, or waiting to generate, claims with corresponding Service Lines specific to that patient.

Payer/Payer Category

This field contains a dropdown menu of Payer/Rate Groups or Payer Categories. The radio button options ('Payer' or 'Category') to the right of this field, dictate which type of items are displayed in the dropdown menu. Payer Categories can be added and edited from the 'Payer Category' Code Table on the Administration menu. Payer Categories are associated to Payer/Rate Groups from the Payer/Rate Groups screen. Only items that were active within the selected 'From Date' and ' To Date' date range will display in the dropdown.

Services

This field displays a checkbox list of all Billable Services associated with the selected Payer or Payer Category that have an 'Effective On' and/or 'Effective To' date that falls within the selected 'From Date' and ' To Date' date range.

Total Units of Service

This field displays the total number of all units, for all Service Lines, for each claim displayed in the grid.

Total Dollars Claimed

This field displays the total amount (US Dollars) of all Service Lines, for each claim displayed in the grid.

Receiver Format

This field is found in the 'Export' section of the screen. This dropdown menu lists available Receiver Formats that have been configured using the 'Receiver Format' screen, found in the Third Party Billing (Advanced) sub-menu on the Accounting menu.

Unsubmitted Only

This checkbox field is found in the 'Export' section of the screen. With this option checked, it limits the 837I (Institutional) 'Show 837' and 'Export 837' features to generating 'UnSubmitted' claims data only. Unchecking this option renders all claims ('Submitted' and 'UnSubmitted') data when using these features.

Grid Columns

Claim ID

This column displays the system generated reference ID assigned to the claim. This ID is assigned when the claim is generated using the 'Generate' function of the screen.

Patient ID

This column displays the 'Patient ID' of the patient for whom the claim is generated.

Patient Name

This column displays the full name of the patient for whom the claim is generated.

Srv. Start

This column displays the earliest 'Service Start' date associated with the Service Line items within the claim.

Srv. End

This column displays the latest 'Service End' date associated with the Service Line items within the claim.

Chrg. Units

This column displays the total number of charged units for all Service Lines within the claim.

Chrg. Amt.

This column displays the total charged dollar amount of all Service Lines within the claim.

Clm. Units

This column displays the total number of claimed units for all Service Lines within the claim.

Clm. Amt.

This column displays the total claimed dollar amount of all Service Lines within the claim. This is the total amount that will be billed to the payer for that claim.

Status

This column displays the current claim status ('Submitted' or 'UnSubmitted').

Last Submit Date

This column displays the last date the claim was submitted for billing. This column only applies to 'Submitted' claims.

Command Buttons

(Patient Search)

This ellipsis button is located to the right of the 'Patient ID' field. Clicking this button opens the 'Patient Search' window. This window is used to help search for and select a patient using patient specific identifying information. The selected patient ID will display in the 'Patient ID' field.

Select All

After a 'From Date' and 'To Date' has been established and a 'Payer/Payer Category' has been selected, clicking this button will select all billable services listed in the 'Services' field.

UnSelect All

Clicking this button will deselect any selected billable services listed in the 'Services' field.

View claims

After making all required 'Service Criteria' selections, clicking this button will retrieve any previously generated billing claims that match the selections made.

Generate

After making all required 'Service Criteria' selections, clicking this button will generate billing claims based on the selections made and the configured Billable Services.

Clear Criteria

This button resets all 'Service Criteria' selection fields, and clears all claims from the 'Claims' grid.

Edit Service Lines

After selecting a claim from the grid, clicking this button opens the 'Billing Service Line Management' application window. From this application window details of individual Service Lines within a claim can be reviewed, edited, or deleted to accommodate highly unusual circumstances prior to exporting the claim into a billing export file. *See Billing Service Line Management topic for more information.

View Charge Status

After selecting a claim from the grid, clicking this button opens the 'Missing or Invalid Charges' pop-up application window. This window displays details about 'Managed' and 'Unmanaged' Services that have missing or invalid charges for the Service Line items within the selected claim. There is a 'Search Text' field where a keyword can be entered to be searched for in the text. There are command buttons below that field which are used to direct the keyword search (Find Forward, Find Back, Find All). The Save to File button opens another pop-up window allowing the user to browse the computers file system and save the details to a text file. Clicking on Close will close this window and return the user to the Claims Generator screen. *See below Procedure section for more information.

Reset Claim Status All

This button is only enabled if one or more claims appearing on the 'Claims' grid has a status of 'Submitted'. Clicking this button will bring up a 'Claims Generator' confirmation dialog box confirming you want to reset the status of all displayed claims to 'UnSubmitted'. Clicking Yes sets all 'Submitted' claims appearing in the grid to the status of 'UnSubmitted'. The grid will refresh to show the updated status for all displayed claims. For facilities submitting EDI files, such as an 837P file, this is a very useful function because it allows users to avoid having to delete then regenerate claims prior to re-exporting them. When an 'UnSubmitted' claim is exported, a Claim Frequency Type Code value of 1 (Original) is exported to component/sub-element CLM05-3 of Loop 2300 on an 837P EDI file. A value of 6 (Corrected) is exported for claims with a status of 'Submitted', which is generally not accepted by Payers.

Reset Claim Status Selected

This button is only enabled if one or more claims appearing on the 'Claims' grid has a status of 'Submitted'. After selecting a 'Submitted' claim from the grid, clicking this button will bring up a confirmation message confirming you want to reset the status of the selected claim to 'UnSubmitted'. Clicking Yes on the confirmation dialog completes this process, setting the selected claim to the status of 'UnSubmitted'. The grid will refresh to show the updated status of the selected claim.

Delete All

Clicking this button brings up a 'Claims Generator' confirmation dialog box confirming you want to delete all claims that appear in the grid. Clicking Yes deletes all displayed claims.

Delete Selected

After selecting a claim for the grid, clicking this button brings up a 'Claims Generator' confirmation dialog box confirming you want to delete the selected claim. Clicking Yes deletes the claim.

Show 837

This button is located in the 'Export' section of the screen. Currently, this export feature is reserved for 837I (Institutional) EDI file types and requires special 'Receiver Format' configuration. Clicking this button opens the '837 Content' dialog window. *See below Procedure section for more information.

Export 837

This button is located in the 'Export' section of the screen. Currently, this export feature is reserved for 837I (Institutional) EDI file types and requires special 'Receiver Format' configuration. Clicking this button opens a 'Safe File' dialog window. *See below Procedure section for more information.

Clicking this button closed the Claims Generator screen.

Procedures

How to View Existing Claims
1.) Using the 'Service Criteria' section of the screen, select a calendar date or enter a 'From Date' and 'To Date'. These date fields are used to filter the displayed claims based on each claim's Service Line Date(s) of Service. 2.) Select a 'Payer/Payer Category' from the dropdown menu. To switch from the default of 'Payer' selections, click the radio button to the right labeled 'Category'. 3.) In the 'Services' field, check desired individual Billable Services or use the Select All button to check all Billable Services displayed. 4.) (Optional) Enter a patient ID into the 'Patient ID' field. Use the ellipsis button to open the Patient Search pop-up window to find a specific patient. Entering a patient ID in this field limits the claim output to Service Lines specific to that patient. 5.) Click on the View Claims button. 6.) All existing (previously generated) claims that meet the entered 'Service Criteria' will display in the 'Claims' grid. 7.) If no claims appear in the grid, then they will have to be generated. *See below Procedure for how to generate new claims.

How to Generate New Claims
1.) Using the 'Service Criteria' section of the screen, select a calendar date or enter a 'From Date' and 'To Date'. These date fields are used to filter the displayed claims based on each claim's Service Line Date(s) of Service. 2.) Select the 'Payer/Payer Category' from the dropdown menu that needs claims generated. To switch from the default of 'Payer' selections, click the radio button to the right labeled 'Category'. 3.) In the 'Services' field, check the desired individual Billable Services or use the Select All button to check all Billable Services displayed. 4.) (Optional) Enter a patient ID into the 'Patient ID' field. Use the ellipsis button to open the Patient Search pop-up window to find a specific patient. Claims generated will be specific to the charges made against the selected patient. 5.) Click on View Claims. If claims matching the entered 'Service Criteria' have been previously generated, they will appear on the grid. The Generate button will become enabled for generating new claims. 6.) Click on Generate. Claims will be generated based on the selections made as well as the configured Billable Services selected, and will display in the grid. IMPORTANT NOTES: - Claims are grouped in the grid by 'Status'. Claims with a 'Submitted' status have been exported to an EDI file using the Billing Export window on the File menu. - Claims are generated based on Charges, but can be packaged differently depending on the 'Service Criteria' selections. This is by design as a facility's billing cycle is not going to correspond with Billable Services rendered to individual patients. - Methasoft allows for up to 49 individual Service Lines to be generated per Claim. This is the maximum number of Service Lines allowed per the 5010 837 Professional (837P) format standards.

How to Edit the Service Lines of a Claim
1.) Using the 'Service Criteria' section of the screen, select a calendar date or enter a 'From Date' and 'To Date'. These date fields are used to filter the displayed claims based on each claim's Service Line Date(s) of Service. 2.) Select the 'Payer/Payer Category' associated with the Service Line(s) that needs to be edited. To switch from the default of 'Payer' selections, click the radio button to the right labeled 'Category'. 3.) In the 'Services' field, check the desired individual Billable Services or use the Select All button to check all Billable Services displayed. 4.) (Optional) Enter a patient ID into the 'Patient ID' field. Use the ellipsis button to open the Patient Search pop-up window to find a specific patient. 5.) Click on View Claims. Existing claims matching the entered 'Service Criteria' will appear in the grid. 6.) Find and select the claim containing the Service Line(s) that need to be edited from the grid. 7.) Double-click on the selected claim item in the grid or click on the Edit Service Lines button. 8.) The 'Billing Service Line Management' application window will appear. *See Billing Service Line Management topic for more information. 9.) From this application window, make the desired edits to the Service Line(s). 10.) After all desired edits have been made, click on the Save button. 11.) Click on the Close button, to close the 'Billing Service Line Management' application window and to be returned to the Claims Generator screen.

How to View the Charge Status of a Claim
1.) Using the 'Service Criteria' section of the screen, fill in the search fields to best narrow down the desired claim(s) to be displayed in the grid. 2.) Click on the View Claims button. 3.) Find and select the claim from the grid. 4.) Click on the View Charge Status button. The 'Missing or Invalid Charges' pop-up dialog box will appear. 5.) Review the displayed details about missing or invalid charges that may need to be addressed prior to submitting the claim for billing. - Enter a keyword into the 'Search Text' box. Use the Find Forward, Find Back, and Find All buttons to search the displayed details for specific charge information. - The Save To File button allows for saving the displayed details to a text(.txt.) file on the computer's file system. 6.) After reviewing and/or saving the details, click on the Close button to be returned to the Claims Generator screen.

How to Reset Submitted Claims Status to UnSubmitted
NOTE: 'Submitted' claims are claims that have been exported to an EDI export file using the Billing Export window on the File menu. The status of one or more 'Submitted' claims can be reset as needed for re-submission of EDI export files. *See the Billing Export topic for more information. Reset Claim Status All 1.) Using the 'Service Criteria' section of the screen, fill in the search fields to best narrow down the desired 'Submitted' claim(s) to be displayed in the grid. 2.) Click on the View Claims button. 3.) To reset all 'Submitted' claims appearing in the grid to the status of 'UnSubmitted', click the Reset Claim Status All button. 4.) The 'Claims Generator' dialog box will pop-up verifying that you are sure you want to reset all displayed 'Submitted' claims to the status of 'UnSubmitted'. 5.) If you are sure, click Yes. This will reset all displayed 'Submitted' claims to the status of 'UnSubmitted' and will refresh the grid to display the new status. Reset Claim Status Selected 1.) Using the 'Service Criteria' section of the screen, fill in the search fields to best narrow down the desired 'Submitted' claim(s) to be displayed in the grid. 2.) Click on the View Claims button. 3.) Find and select the 'Submitted' claim from the grid. Click the Reset Claim Status Selected button. 4.) The 'Claims Generator' dialog box will pop-up verifying that you are sure you want to reset the selected claim to the status of 'UnSubmitted'. 5.) If you are sure, click Yes. This will reset the selected claim to the status of 'UnSubmitted' and will refresh the grid to display the new status.

How to Delete Claims
Delete All 1.) Using the 'Service Criteria' section of the screen, fill in the search fields to display the desired claim(s) that need to be deleted in the grid. 2.) Click on the View Claims button. 3.) To delete all claims displaying in grid, click the Delete All button. 4.) The 'Claims Generator' dialog box will pop-up verifying that you are sure you want to delete all displayed claims. 5.) If you are sure, click Yes. This will delete all displayed claim and will refresh the grid displaying no claims. Delete Selected 1.) Using the 'Service Criteria' section of the screen, fill in the search fields to display the desired claim(s) that need to be deleted in the grid. 2.) Click on the View Claims button. 3.) In the grid, find and select the claim that needs to be deleted. Click the Delete Selected button. 4.) The 'Claims Generator' dialog box will pop-up verifying that you are sure you want to delete the selected claim. 5.) If you are sure, click Yes. This will delete the claim and will refresh the grid.

How to Show and Export 837I (Institutional)
IMPORTANT NOTES: - The 'Export' section of the Claims Generator screen is currently only for 837I (Institutional) EDI files. To export 837P (Professional) files, use the Billing Export Button on the File Menu. *See the Billing Export topic for more information. - To export 837I files the following configurations need to be completed: -- On the selected Receiver Format, the 'Format Description' needs to contain the character string: '837I' -- On the Patient Billing Episode, these fields have to be filled in: - Admission Type Code - Admission Source Code - Patient Status Code -- On Billable Services - Billable Service Additional Information screen, found by clicking the More... button, this field needs to be filled in: - Service Description (Institutional). 1.) After the above configurations have been completed; using the 'Service Criteria' section of the screen, select a calendar date or enter a 'From Date' and 'To Date'. These date fields are used to filter the displayed claims based on each claim's Service Line Date(s) of Service. 2.) Select the 'Payer/Payer Category' from the dropdown menu. To switch from the default of 'Payer' selections, click the radio button to the right labeled 'Category'. 3.) In the 'Services' field, check the desired individual Billable Services or use the Select All button to check all Billable Services displayed. 4.) (Optional) Enter in a patient ID into the 'Patient ID' field. Use the ellipsis button to open the Patient Search pop-up window to find a specific patient. 5.) Click on View Claims. 6.) Select the 873I configured 'Receiver Format' from the dropdown menu. 7.) (Optional) Check the box marked 'Unsubmitted Only' if you want the 873I output to contain only 'UnSubmitted' claims. Leave this box unchecked to include both 'Submitted' and 'UnSubmitted' claims in the output. 8.) (Optional) Click the Show 837 button. This will display the 837I export file data in a '837 Content' dialog pop-up window. - This dialog window has the same keyword search features as the 'Missing or Invalid Charges' dialog window. - This 'Show' feature allows the user to review the 837I export data prior to saving the file to the computers file system. 9.) Click on the 837 Export button. This will open a dialog window allowing the user to choose where, on the computers file system, to save the export file. 10.) Browse to the desired folder destination on the file system. 11.) Name the 837I export file in the 'File Name' field. 12.) Click Save. A confirmation dialog box will appear stating the file has been successfully written to the selected folder. 13.) Click OK to close the window and be returned to the Claims Generator screen.

Considerations

Generate Claims for the Same 'Service Criteria' Parameters as Being Exported.

Whenever possible, it is highly recommended to generate claims using the same 'Service Criteria' (dates, payers, and services) parameters as those being exported. This recommendation is to help avoid submitting a subset of the service lines that have been generated into a claim. Keep in mind, Claims are a compilation of Service Lines based on the 'Service Criteria' selections. It's important to export the same Service Lines in the claim that have been generated. The 'Submitted' status (Frequency type code value) is applied at the claim level, not the Service Line level. So generating a claim using one set of 'Service Criteria' parameters and then exporting claims using a different set of parameters, will result in missing service lines. The claim as a whole will show as 'Submitted', however there may be Service Lines within that claim, that have not been submitted. Which could result in a delay in payments from the Third Party Payer.

Claim Status - 'UnSubmitted' and 'Submitted' - EDI Export File Functionality Implications

The Status of a claim in Methasoft is currently limited to 2 possibilities:

- UnSubmitted - the claim has been generated, but not exported to an EDI file using the Billing Export window.

- Submitted - the claim has been exported to an EDI file using the Billing Export window on the File menu.

This is very important in facilities exporting EDI files to be submitted to Third Party Payers, because the Status of a claim determines which Claim Frequency Type Code value is exported to CLM05-3 of an 837P EDI export file. If the status of a claim is 'Unsubmitted', then any service lines exported for that claim will be exported with a Claim Frequency Type Code value = 1 indicating 'Original'. If the status of a claim is 'Submitted', then any service lines exported for that claim will be exported with a Claim Frequency Type Code value = 6 indicating 'Corrected', which is often rejected by Payers. Claims only have an 'UnSubmitted' status after generation and prior to be exported for the first time, or after having their statuses reset using either of the Reset Claim Status buttons.