Unpaid Claims. 70 Royal Little Drive. Providence, RI Copyright Ingenix. All rights reserved. Updated: 9/20/11

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2 Table of Contents 1 Claim Summary Fields and Features Electronically Checking Claim Status Checking Individual Claim Status Checking Batch Claim Status Unpaid/Inactive Claims... 9 ii

3 1 Claim Summary Fields and Features CLAIM SUMMARY FIELDS AND FEATURES Field Back Select All Deselect All Filing Limit Description Clicking on the Back button will bring you back to the Unpaid/Inactive Claims screen where you can select an aged week of unpaid/inactive claims to work on for a particular financial class. All claims included in the unpaid/inactive claims age for the financial class you chose to work on will be selected when the Select All button is clicked and a selected claim is indicated by a check mark in the Select column on the claim line. Select All is convenient to use if you need to perform an action on the selected batch of claims, i.e., electronically checking claim status, rebilling claims, or adding a note. When the Select All button is clicked, individual claims can be de-selected by clicking on the check mark in the Select column. Clicking on the Deselect All button will de-select any selected claim. A selected claim is indicated by a check mark in the Select column on a claim line. De-selecting a claim or all claims will remove the check mark. Claims approaching filing limit are highlighted red as a visual indication that these claims need to be handled in a timely manner. For most payers, a claim will turn red 25 to 30 days before its actual filing limit will be reached. Inactive Limit Claim Summary Line Claims that have not been worked in 30 days are considered inactive and inactive claims are highlighted tan as a visual indication that these claims need to be worked. A claim summary line for each claim included in the unpaid/inactive claims age for the financial class you selected displays. The claim summary line shows the patient's name, CareTracker ID number, date of birth, the insurance plan, the patient's subscriber number, the status of the claim, the claim's last activity date, the original claim date, the claim's age, the oldest service date, the provider, the original amount on the claim, the remaining 1

4 CareTracker PDF- Unpaid Claims CLAIM SUMMARY FIELDS AND FEATURES Field Description open balance, the last transaction date, the description of the last transaction, activity date, and activity notes. More detailed claim summary information will display when an individual claim summary line is clicked. Rebill Claim Status Notes Status Save Claim Summary Screen Claim This Rebill button is used to rebill a batch of claims. Select the claims you need to rebill either by clicking on the Select All button or by clicking in the Select column for the appropriate claims and then click on the Rebill button. Rebilling claims changes their status to 'New' and moves them to the New/Pending column on the Claims Worklist screen. Claims in the New/Pending column will be transmitted during your next bill run. Every evening, CareTracker will automatically check the status of every claim on which there is an outstanding balance. A claim is checked for the first time after seven days it is flagged as "TRANS OPEN". If the claim status continues to remain "In process" the second automated check is performed three days after the first check. Since a third check is not performed by CareTracker it is best practice to call the payer and follow up on the claim or manually recheck the claim status. There are particular statuses returned from a payor when a claim's status is checked: 'In Process,' 'Finalized', 'Set to Pay', 'Set to Deny', 'Pending In Review' and 'Not Found'. Each claim will be updated accordingly when the automated batch claim status check is complete. When a status of 'Set to Deny', 'Pending in Review' or 'Not Found' is returned during an automated batch claim status check, the claim will be updated and flagged in the Claims Worklist link under the Billing section of the Dashboard. Note Enter an activity note in regards to the selected claims in the "Notes" field and click on the Save button. The note will be saved in the Activity Notes section of each selected claim and adding a note re-starts the claims aging used to determine inactive claims. The "Status" field can be used to manually change the status of the selected claims. 'Select' defaults in the "Status" field however, the selected claims' statuses can be changed by selecting the appropriate status from the "Status" field drop-down list, i.e., 'Payer Edits', 'Not Found', 'Claim Status Denial', 'Missing Info', or 'In Review'. Manually changing the claims status will move the selected claims to the corresponding column on the Claims Worklist screen. Clicking on the Save button will save an activity note that has been entered in the "Notes" field and/or a claim status that has been selected from the "Status" list. The Claim Summary screen displays when an individual claim line is clicked. In this screen, actions can be performed on the selected claim only. The top part of the Claim Summary screen displays all of the information 2

5 Unpaid/Inactive Claims CLAIM SUMMARY FIELDS AND FEATURES Field Information Notes Rebill To ==> Form Type Rebuild Paper Claim View Paper Edit Description that was included on the claim, i.e., status, balance, last activity date, subscriber number, insurance company, insurance plan, billing and servicing provider, billing provider UPIN and NPI, referring provider, admission date (if applicable), and authorization number (if applicable), provider's tax ID, provider's enrollment status in insurance and the effective date of enrollment. These fields cannot be edited however, the billing provider and the referring provider's insurance number details can be viewed by clicking on the respective provider's name. Note An activity note can be added to the claim by entering the note in the "Notes" field and then clicking on the Save button. Adding a note re-starts the claims aging used to determine inactive claims. When the needed information has been added to and or edited to the claim or the patient's demographic, the Rebill To==> button must be clicked in order to rebill the claim. When a claim is rebilled, it will be placed in the New/Pending column on the Claims Worklist screen and will be transmitted during your next bill run. Before clicking on the Rebill To==> button, verify the form type selected in the "Form Type" field. A form type must be changed before clicking on Rebill To==> button. ANSI form types are claims that are electronically transmitted to a payer and paper form types are claims forms that are dropped to paper that must be printed from CareTracker and then mailed to a payer. The default form type for the insurance plan the claim needs to be sent to is selected in the "Form Type" field. When a form type needs to be changed, selected the appropriate form from the "Form Type" list and click on the Rebill To==> button. When ANSI format is changed to paper, CareTracker ensures the proper information is present on the claim form before releasing the claim to print. The Rebuild Paper Claim button can be used to print paper claims without CareTracker verifying the accuracy of the information. The form type selected in the "Form Type" field must be a paper form. When the Rebuild Paper Claim button is clicked, the claim displays in a window, right-click on top of it and select 'Print' from the grey pop-up menu. The claim will be removed from Claims Worklist when the Rebuild Paper Claim button is clicked. The claim will display in a window when the View Paper claim button is clicked. Clicking on the View Paper button does not remove the claim from the Claims Worklist link. Clicking on the Edit button on the Claim Summary screen displays the Encounter window from which you can add and/or edit claim information including the location, place of service, Additional Claim Info, referring provider, modifiers, and diagnoses. Dates of service, procedure codes, fees, 3

6 CareTracker PDF- Unpaid Claims CLAIM SUMMARY FIELDS AND FEATURES Field Description the insurance company and the amount of the claim may not be edited from this pop-up. Note Claim Status Status Field Save Status Column Activity Date Activity Notes Key Every evening, CareTracker will automatically check the status of every claim on which there is an outstanding balance. A claim is checked for the first time after seven days it is flagged as "TRANS OPEN". If the claim status continues to remain "In process" the second automated check is performed three days after the first check. Since a third check is not performed by CareTracker it is best practice to call the payer and follow up on the claim or manually recheck the claim status. There are particular statuses returned from a payor when a claim's status is checked: 'In Process,' 'Finalized', 'Set to Pay', 'Set to Deny', 'Pending In Review' and 'Not Found'. Each claim will be updated accordingly when the automated batch claim status check is complete. When a status of 'Set to Deny', 'Pending in Review' or 'Not Found' is returned during an automated batch claim status check, the claim will be updated and flagged in the Claims Worklist link under the Billing section of the Dashboard. The Claim Status button on the Claim Summary screen enables manual recheck of a claims status without having to wait for the automated process. Note The "Status" field can be used to manually change the status of the claim. 'Select' defaults in the "Status" field however, the status can be changed by selecting the appropriate status from the "Status" list, i.e., 'Payer Edits', 'Not Found', 'Claim Status Denial', 'Missing Info', or 'In Review' and then clicking on the Save button. Manually changing the claims status will move the claim to the corresponding column on the Claims Worklist screen. Clicking on the Save button will save an activity note that has been entered in the "Notes" field and/or a claim status that has been selected from the "Status" list. The status column shows the claims current status and all of the status steps the claim has gone through. Logs the date and time of all activity taken on the claim. Claim errors occur when a claim does not meet specific requirements set by CareTracker and/or payers. Errors display under the Activity Notes section of the Claim Summary screen as a mnemonic code along with the error description. Error descriptions direct you as to what pieces of claim information needs to be fixed before the claim can be successfully transmitted to a payer. Example: "BPINNO - Billing Provider/Insurance Number is missing for this particular Billing Provider/Insurance combination" instead of BPINNO only. By clicking on the Key link, a list of all the possible system note codes and 4

7 Unpaid/Inactive Claims CLAIM SUMMARY FIELDS AND FEATURES Field Description their corresponding message will display. This key can be used to decipher a code that you do not understand. Link Operator Claim Batch ID Procedures Payment Separate Claim The Acknowledgement and the Report electronically received into CareTracker from a payer that included the claim will be accessible from the Claim Summary screen. The Acknowledgement report can be viewed by clicking on the ANSI 837 link and the Report can be viewed by clicking on the Report link. The Report shows all the claims that were transmitted in the same claim batch as the current claim's summary you are viewing. Logs the operator who performed each action that has been taken on a claim. This shows the claim batch identification number. Each procedure line included on the claim will display in the lower part of the Claim Summary screen. Under each procedure line will be a record of all the financial transactions linked to each procedure. The Payments screen displays when the Payment link is clicked from which a financial transaction, i.e., payment, adjustment, or transfer, for the respective procedure line can be entered. When multiple procedure codes appear on one claim, those procedures can be separated to different claims by clicking on the Separate Claim link. 5

8 CareTracker PDF- Unpaid Claims 2 Electronically Checking Claim Status Claim status is automatically checked every evening for every claim that has an outstanding balance. Typically, a manual claims status check is not necessary. However, if you need to manually check claim status you do so individually or in a batch. Note CareTracker automatically performs a status check 7 days after the claim is set to Trans Open. If the claim is not finalized, CareTracker automatically performs another check 3 days later and then flags the claim as Not Found. 2.1 Checking Individual Claim Status Claim status for individual claims can be checked from any application in CareTracker where the Claim Summary screen displays. To individually check claim status electronically: 1. Click the Home module and then click the Dashboard tab. CareTracker displays the Practice Dashboard by default. 2. Click the Unpaid link under Claims Status in the Billing section of the Dashboard. CareTracker displays the Claims Status Filter Options. 3. Select the desired filter options and then click Go. CareTracker displays the Unpaid/Inactive claims, broken down by financial class and by week. The total inactive claims for a financial class displays in the Inactive column. Totals for all unpaid claims for a financial class displays in the Total column and for each week, the total number unpaid claims displays in the Totals row. 4. Determine the unpaid/inactive claims for which you would like to electronically check claim status and then click on the corresponding number. CareTracker displays a claim line for all corresponding Unpaid/Inactive claims displays with the patient's name, ID number, date of birth, subscriber number, the insurance plan for which the claim was transmitted, the claim status, last activity date on the claim, claim date, claim age, oldest service date on the claim, the provider on the claim, the original amount, balance remaining, and the last activity notes saved for the claim. 5. Click on a claim summary line. CareTracker displays the Claim Summary in the lower frame of the screen. 6. Click the Claim Status button. CareTracker displays the Claim Status History window which includes all previous status checks that have occurred including, the date of the status check, the operator who performed the check, the claim status category, and the Claim Status code. 7. Click the Claim Status button in the top right corner of the Claim Status History window to perform another claim status check. When the claim status check is complete, the status of the current claim is automatically updated and the claim check information display in the Claim Status History window. Possible statuses include: In Process- When a claim status check is complete and the payer returns that it is In Process, CareTracker sets the claim status to In Process. When a claim is set to In Process it's status will not be checked during a batch electronic claims status check for 6

9 Unpaid/Inactive Claims the next seven days. However, you can manually recheck the individual claim's status, overriding the seven day period. Finalized- When a claim status check is complete and the payer returns that it is Finalized, CareTracker sets the claim status to Finalized. A Finalized claim will have the details of the finalization listed under the Activity Notes section of the Claims Summary screen. After a claim has be set to Finalized, no additional electronic claim status checks can be performed. Set to Pay- When a claim status check is done and the payer returns that it is Set to Pay, CareTracker will set the claim status to set to pay. Set to Pay claims are going to be paid on by the respective payer. These claims will remain in Unpaid/Inactive claims until they are paid or adjusted off in full. After a claim has be set to Set to Pay, no additional electronic claim status checks can be performed. Set to Deny- will send back as part of the claim status process. Any of these messages that constitute a claim status denial will set the claim's status to Set to Deny. In addition to these claims being flagged in the Unpaids/Inactive link, they are flagged in the Claims Worklist link as well since they have been denied and will require follow up. After a claim has been set to Set to Deny no additional electronic claim status checks can be performed. Pending In Review- There are also Claim Status messages that will come back from the payer that the claim is In Review. Any of these statuses will set the claim to In Review. In Review claims should be followed up on until they have been adjudicated by a payer. Not Found- Any payer that has electronic claim status where the claim is not on file after seven days of the original claim date will be set to Not Found status. Note: When a claim's status has been returned, except for Set to Pay, the claim will be moved to the corresponding column on the Claims Worklist screen. 8. To view the details of the check, click on the Details button. 2.2 Checking Batch Claim Status To batch check claim status electronically: 1. Click the Home module and then click the Dashboard tab. 2. Click the Unpaid/Inactive Claims link under the Billing section of the Dashboard. CareTracker displays the Claims Status Filter Options. 3. Select the desired filter options and then click Go. CareTracker displays the Unpaid/Inactive claims, broken down by financial class and by week. The total inactive claims for a financial class displays in the Inactive column. Totals for all unpaid claims for a financial class displays in the Total column and for each week, the total number unpaid claims displays in the Totals row. 4. Determine the unpaid/inactive claims for which you would like to electronically check claim status and then click on the corresponding number. CareTracker displays a claim line for all corresponding Unpaid/Inactive claims displays with the patient's name, ID number, date of birth, subscriber number, the insurance plan for which the claim was transmitted, the 7

10 CareTracker PDF- Unpaid Claims claim status, last activity date on the claim, claim date, claim age, oldest service date on the claim, the provider on the claim, the original amount, balance remaining, and the last activity notes saved for the claim. 5. Select the batch of claims to electronically check the status of by clicking on the Select All button or by clicking the checkbox in the Select column next to each claim for which you want to check status. 6. Click the Claim Status button. Note: A claim's status can not be electronically checked until several days after its last transmission date which allots for any transmission lag time and for the claim to have time to have been accepted into the payer's system. 7. When the status of all selected claims has been electronically checked, the Claim Status window displays showing the results of the check. It lists the number of claims selected to check, the number of claims actually updated, the number of claims that were skipped, and the reason each claim was skipped if applicable. Reasons a claim were skipped for an electronic claim status check include, insurance not setup for electronic claim status, your company is not setup to do non-participating claim status, the minimum number of days since the claim was sent has not elapsed, and the minimum number of days since the last in process status has not elapsed, claim status is already finalized. The claim statuses will be updated as described above under the individual claim status mode. 8. When each claims status is updated, the claims that require follow up will be moved to the corresponding column in the Claims Worklist link. Claims that receive a status of Set to Pay will not be moved to the Unbilled Claims link because they do not require any follow up. Claims remain as Claims Worklist until the required information is added and/or edited and rebilled. Note: CareTracker waits a minimum of seven days from the first day a claim's status was checked before flagging it as Not Found and the system will not allow you to re-check a claim's status until seven days after the last check was electronically performed. 8

11 Unpaid/Inactive Claims 3 Unpaid/Inactive Claims Unpaid claims are claims that have been submitted to an insurance company but have not been paid. Inactive claims are claims that are not only unpaid, but also have not had any follow-up activity on them for the last thirty days. Unpaid and Inactive claims are aged by week, broken down by financial class, and can be worked from the Unpaid/Inactive links in the Claims section of the Practice Dashboard. Inactive claims are highlighted in tan and claims that are nearing their filing limit are highlighted in red as a visual alert that these claims need to be worked immediately. From this list, you can drill down into each Unpaid/Inactive claim that requires follow up. When an inactive claim has been worked it is removed from the inactive category however, if there is no payment or additional activity on the claim for the next thirty days, it is re-categorized as inactive. The number of inactive claims should only be 5-10% of your unpaid claims. As a best practice, you should focus your follow-up activities on the inactive claims category. This will significantly improve the efficiency of your claim follow up activities. CareTracker automatically checks unpaid claims' status every evening with specific payers. It will check the status of all claims with an outstanding balance. When a check is complete, the claim's status is updated, attached to the claims, and if necessary the claim will also be flagged in Claims Worklist if a status of Not Found, Set to Deny or In Review is returned. To work unpaid/inactive claims: 1. Click the Home module and then click the Dashboard tab. CareTracker displays the Dashboard. 2. Click the Unpaid link under Open Claims in the Billing section of the Dashboard. CareTracker displays the Claims Status Filter Options. 3. In the Status field, click on the status of the claims you want to view. Press the Ctrl key while clicking to select multiple statuses. 4. From the Age by list select the age of claims to view. 5. (Optional) From the Fin Class list, select the financial class containing the claims you want to view. 6. Click Go. CareTracker displays the unpaid/inactive claims by financial class and by week. The Inactive column displays the total inactive claims for a financial class. The Total column displays the total unpaid claims for a financial class. The Totals row displays the total unpaid claims for each week. 9

12 CareTracker PDF- Unpaid Claims 7. Locate the claims you want to work and click on the corresponding number in the chart. CareTracker displays a claim line for each unpaid/inactive claim. Click the column headings to sort the columns. Note: You cannot click on a zero total. 8. When a number is clicked, a claim line for all corresponding Unpaid/Inactive claims displays with the patient's name, ID number, date of birth, subscriber number, the insurance plan for which the claim was transmitted, the claim status, last activity date on the claim, claim date, claim age, oldest service date on the claim, the provider on the claim, the original amount, balance remaining, and the last activity notes saved for the claim. 9. To work a claims in a batch: a. Select the checkbox in the Select column next to each claim you want to work or click Select All to select all of the claims. b. Perform the desired action on the claim(s). For example, if you are adding a note in regards to each of the selected unbilled claims, enter the note in the "Notes" field and click Save or to rebill the claims, click Rebill. 10. To review or work an individual claim, click on the claim summary line. CareTracker displays the Claim Summary in the lower frame of the screen. 10

13 Unpaid/Inactive Claims 11. To edit claim information, such as diagnosis code or referring provider, click Edit on the Claim Summary screen. The Encounters window displays the location, place of service, encounter specific claim information, referring provider, diagnosis code and modifiers. Dates of service, procedure codes, fees, the insurance company and the amount of the claim may not be edited from this window. Note: Click the number link next to Rule Set to view descriptions of the rules for the insurance company. This can be helpful when determining the information that needs to be fixed. Click the Key link next to the Activity Notes heading to view a key for deciphering each missing information code. 12. To edit patient demographic information, click the Edit button on the Name Bar. CareTracker displays the Demographics window. 13. Edit the information as needed and then click Save. 14. After editing the claim or patient information, Rebill To. CareTracker will place the claim in the New/Pending category of the Claims Worklist screen and will transmit the claim during the next bill run. Note: When rebilling claims the form type typically is not changed 11