WinFlexOne Version 8 How To Guide. Claims Processing

Transcription

1 WinFlexOne Version 8 How To Guide Claims Processing

2 A. How to Create a Manual Claim: 1. Under Processing and the Claims category, select Claims.

3 2. Select the Open New Claim Input Session option.

4 3. Enter the claim information, starting with Employee SSN or ID field. The employee s data will display and the Service Start Date will default to the current day. 4. Enter the remaining claim information (Claim type, Service end date, Transaction date, Received date, Reference information, Claim hold reason, and Provider). 5. To save your new claim, select the Save and Create New Claim option or the Save Claim option.

5 B. How to Process a Claims Batch: 1. Under Processing and the Claims category, select Process Claims Batch. 2. The batch display defaults to Unposted Claims. The display can be changed to show Posted Claims by selecting the drop-down arrow in the Show only field. 3. The information displayed on this screen can be changed by entering values in the filter fields. Filters can be cleared by selecting the Clear filter option. 4. Click on the Display Options icon in the ribbon toolbar to set display by Company, User ID, or Batch.

6 5. Click the arrow to the left of the batch line item to expand and view the list of claims included in the batch. 6. Select the batches to be posted by placing a checkmark in the checkbox next to the Batch ID number. 7. To print the claims batch, select Print Selected Batches.

7 8. To post the claims, choose Post Selected Batches. The batch will disappear from the Unposted Claims display.

8 C. How to Process ICE Forms: 1. Under Processing and the Claims category, select Process ICE Form. WinFlexOne will display the following screen, which contains the unprocessed ICE forms.

9 2. Double click on a claim to process. 3. The ICE form claim screen allows you to add Reference Information, Adjudicate, Reject, Edit Rejection letter and to display the claim.

10 4. To process the claim form, first select Adjudicated and then choose Process Claims. You will be returned to the list of unprocessed ICE form claims. (Note: The previously processed claim form will still appear, but it will not be able to be processed if selected again. The claim will not be visible the next time the ICE form screen is accessed). 5. The claim will display in the Unposted claims batch screen.

11 D. How to Adjust Claims: 1. Under Processing and the Claims category, select Go To Claim. 2. Enter the Claim ID. The following screen displays the Claim (detail), Disbursement history, and Adjustment history.

12 3. Select Make an Adjustment from the ribbon tool bar. The following adjustment screen will display.

13 4. In the Adjustment amount field, input the correct dollar amount. Enter a positive dollar amount to reverse a previous adjustment. Enter a negative dollar amount to adjust the claim. Enter the reason for the adjustment in the Adjustment reason field. 5. Select OK to save the changes.

14 E. How to Repay a Non-Qualified Expense: 1. Under Processing and the Claims category, select Go to Claim and enter the Claim ID for the participant whose balance due that you want to repay. Select Repay Non-Qualified Expense from the ribbon tool bar.

15 2. The system will automatically populate the Company name, Employee name, and Non-Qualified Expense and Repayment History fields. The employee s NQE balance due will be displayed at the bottom of the screen. 3. Select the Display All Transactions checkbox to view the detail of the NQE balance due history.

16 4. If the employee has a balance due, the Make a Repayment icon will be activated in the ribbon tool bar. Select the Make a Repayment icon. The Non-Qualified Expense Repayment screen will display (Please see below). 5. Enter the Repayment amount. If appropriate, select the Administrative adjustment check box. 6. Enter the Reference number. 7. Enter a Comment if needed. 8. Select OK to save your changes and exit the screen.

17 F. How to Adjust or Substantiate Claims: To adjust or substantiate claims, please follow the steps outlined below. 1. Under Processing and the Claims category, then choose Adjust or Substantiate Multiple Claims. WinFlexOne will display the following screen.

18 2. Enter the Company Code and Employee Number. The Employee Number default is <All>. 3. Select the Transaction Date Filtering based on the age or date of the claims. 4. To find the claims that match your search filter, select Get Claims. The following screen will be displayed.

19 5. To sort or filter the data displayed above, click on any column heading. The system will sort the data based on your selection. 6. To substantiate or adjust your claims, select the Substantiate or Adjust checkboxes. 7. To print the list of claims displayed, select the Print icon. 8. Choose the Copy to Clipboard option to copy the claim listing another application. 9. Select Apply Changes in ribbon the tool bar to complete the action.

20 G. How to Correct a Benefit Account: To correct a benefit account, please follow the steps outlined below. 1. Select Processing, then Claims, and then choose Correct Benefit Account.

21 2. Enter the Employee s SSN or ID, or select Find Employee in ribbon tool bar.

22 3. The employee information will populate. Select the drop down arrow next to Claim ID to view the list of claims.

23 4. Select the claim by clicking on it once. The claim data will populate.

24 5. You can change claim information by selecting New claim type, Service start date, Service end date, or Transaction date. You can also check the Force Payment from Election option to select the election or plan year to move the paid claim. (Note: You may need to expand the screen view to see the Force Payment election options). The Payment History shows the Plan Year from which the claim is currently disbursed.

25 6. Select Preview Changes. 7. You can view data changes in the Preview Changes window.

26 8. If your changes are correct (plan year, benefit, etc), select Apply Changes. You will receive the confirmation message The claim has been successfully corrected.

27 9. The Payment History Window will populate with the disbursement change. 10. Verify employee s account balances to confirm successful claim movement.

28 H. How to Process Manual Card Use Verifications: 1. On the Category Selector, choose Processing. 2. Expand the Claims menu on the task bar.

29 3. From the Claims menu, select Go to Claim. 4. Enter your Claim ID. Once you have entered your Claim ID select OK. 5. The adjust claim form window will display with your claim information. From the ribbon tool bar select Set Hold Status.

30 6. The Set Hold Status box will be displayed. Select the drop down arrow and select Not on hold. 7. Once you have selected the appropriate hold type, select OK. 8. Please note that the Substantiation Type and Date fields have updated appropriately to complete the substantiation of the claim.

31 I. How to Adjust or Substantiate Multiple Claims for Card Use Verifications: 1. On the Category Selector, choose Processing. 2. From the Claims menu, select Adjust or Substantiate Multiple Claims. 3. From the ribbon tool bar select Find Employee.

32 4. You may use any of the search criteria to locate an employee. 5. Click on the correct employee and select OK. 6. On the ribbon tool bar select Get Claims.

33 7. Select the claim(s) that you would like to substantiate (or adjust). 8. On the ribbon tool bar select Apply Changes. 9. A warning message will be display. Verify your selections and choose Yes.

34 10. The process is now complete. The system will bring you back to the Adjust or Substantiate Multiple Claims form window.