A. Insurance Charge Workflow
1. All charges saved and not yet billed fall under NEW status. Additionally, any charge crossed over from EHR to the billing would also appear in the “NEW” status on the Enter Charges screen. Save the charge with status Bill to PR to post the charge.
2. After the first batch generation & submission of the claim, the line status is changed by the system to “Claim Sent to PR”. This indicates the claims were batched and submitted once.
3. Use the “Rebill to PR” line status to refile a claim. The line status would be changed to “Claim Rebilled to PR” on the next batch or subsequent refiling and batching of the claim. A charge if in “Rebill to PR” indicates that the claim/line hasn’t yet been batched after it was put to the rebill status.
4. The same workflow would apply to Secondary or Tertiary claims. The status for the secondary claims would begin with “Bill to SE” and for tertiary – “Bill to TR”.
5. When batching is done, all the claims sitting in Bill to PR(/SE/TR) & Rebill to PR (/SE/TR) are pulled up by the system for batching to electronic batch/paper depending on their method of submission.
6. An open line can be closed with/without an adjustment. If there is no adjustment, the line status is closed with a “Paid Close” status. If there is an adjustment on the line, the line can be closed with a “WO Close” status.
However, in cases when practices receive patient payments prior to claim generation and need to send the applied patient payments info in the electronic claim, they can opt to do so as explained in the section beneath.
Posting Patient Payments Prior to Claim Generation
A feature that is made available and is useful for out-of-network billing when the patient payment amount has to be received by the payer and included in the claim. The applied patient payments can be made to populate in the electronic claim even if the full balance on the line is in a closed status. After the patient payment is applied if the line has no balance left, the system will still permit to keep the line status in the open Bill_to_PR status for generating the electronic claim.
*The below rule (with the flag as “TRUE”) has to be added in the electronic rules section in the Billing Options for populating the payment amount in the electronic file:
<PAYERID>:INCLUDEPATIENTPAYMENT:<TRUE/FALSE>
*When enabled the payment info is populated in Loop 2300 with qualifier F5.
7. If there is a balance on an insurance charge, the line status can be moved to a Bill to PT or Bill to GR status while applying the payment or from the Edit Charges screen.
B. Patient/Guarantor Charge Workflow
1. Charges are billed to the patient/guarantor in cases when there is a balance in the charge even after payment by primary, secondary, and tertiary insurances(as applicable). Charges can also be billed to patients when the insurance for the patient is no longer valid or if the account type of the patient is self-pay.
2. Any patient bill can be posted with a “Bill to PT” (abbrev. for Bill to Patient) or “Bill to GR” (abbrev. for Bill to Guarantor) status. The former status is used when the patient is the responsible party and the statement needs to go out to the patient. If the responsible party is the Guarantor, use the Bill to GR status.
3. As in the case of an insurance line posting, the Bill to PT lines can be closed with a “Paid Close” or “WO Close”.