About
The Claims Manager is used to edit, submit, and track the status of your generated claims in NPAWorks.
To generate claims, you would first use the Claims Wizard - once you complete the process it will direct you back to the Claims Manager.
Overview
Once you have generated claims via the Wizard, you can further manage them in this window using the various options below.
- Save All changes made to claims.
- Refresh to Abandon Changes or to retrieve updates from elsewhere in NPAWorks.
- Select All displayed claims.
- Deselect All displayed claims.
- Review/Edit selected claims.
- Bulk Update - edit the Submission Date, Type, Status, Status Reason, or Notes for multiple claims.
- Release selected claims - This allows you to generate new claims for the associated appointments.
- Print Preview selected claims.
- Print selected claims.
The drop-down next to it provides the ability to make Vertical/Horizontal offsets to better align with the CMS 1500 claims form, and to save these settings for multiple printers.
- Export selected claims.
The drop-down next to it provides the ability to select which export method to use.
Some of these options may not be available depending on your current account settings/integrations - please contact Support if you need certain options enabled.
- Apply Submission Date & Time to selected claims when Printing or Exporting.
Viewing Claim Statuses
The status of claims can be seen in the Claims tab of Claims Manager. When a claim is generated and sent electronically to a clearinghouse the claim status of Submitted is initially assigned.
When Claim is printed and mailed/faxed to the payer rather than sent to a clearinghouse, the user should select Submission Type of Print. The claim status is automatically Submitted and will remain with that status until a payment is manually applied in the Payment Ledger, at which time the status will automatically update to Manual Posting.
Accepted Electronic Claims
Every 30 minutes after submittal, NPAWorks checks for updates from the clearinghouse regarding whether the claim was accepted or rejected. When a clearinghouse accepts a claim, it forwards the claim next to the payer’s EDI. The claim status in Claims Manager changes to Accepted by Clearinghouse, or, infrequently, to Accepted with Errors by Clearinghouse when notification of the clearinghouse status is received by NPAWorks.
Once accepted by the payer EDI, the claim is submitted to the payer for adjudication. When NPAWorks receives the notification that the claim has passed EDI validations the claim status changes to Initially Accepted by Payer EDI.
When NPAWorks is notified that the claim has been adjudicated, electronic remittance advice (ERA) is posted in the system for any charge lines paid, and the claim status changes to 835 Response.
Rejected Electronic Claims
If the claim does not pass clearinghouse validations the status is changed to Rejected by Clearinghouse. Likewise, if the Payer EDI rejects the claim the status changes to Rejected by Payer EDI.
When rejected, the user selects the claim, opens the Claims Ledger tab (See Claims Manager – Viewing Electronic Charge Lines), and clicks the link in the Details field to see the reasons for the rejection.
The user will need to correct the missing or incorrect claim data by:
- Editing the claim, or
- Releasing the claim, correcting the source data, and regenerating the claim.
Once the errors are corrected, the claim can be submitted again from the Claims Manager Claims tab
Claims Ledger tab
From the Claims Manager, select one or more claims and then click on the Claims Ledger tab.
Please note, that the Claims Ledger tab displays individual charge lines, while the Claims tab displays whole claims. Since the Claims Ledger tab contains more columns, it is necessary to page or scroll horizontally to see all columns.
Viewing Charge Line Details
When the ERA 835 Response is received, NPAWorks automatically posts payments to charge lines and updates their Line Status accordingly in the Claims Ledger tab, along with additional information such as payment amount and balances.
Line Status: When auto-posting ERA payments, the amount received is compared to the Expected Reimbursement Amount which uses the practice’s contract rate, as opposed to their fee schedule rates. (These rates are entered in the Funding Source Services in NPAWorks.)
After the 835 file is received, Claim Status will change to “835 Response” and the Line Status is updated as follows:
- Short Pay: Carrier payments were less than expected (Expected Reimbursement Amt > sum of all FS payment(s) – Client Responsibility)
- Overpaid: Carrier payments were more than expected (Expected Reimbursement Amt < All FS payments – Client Responsibility)
- Client Responsibility: When all Carrier(s) payment(s) are applied and Copay, Coinsurance, Deductible, or Miscellaneous values have been transferred to Client Responsibility
- Denied: If the claim was denied
- Complete: Paid in full (Expected Reimbursement Amt = sum of all Carrier Payment(s) + all Client Responsibility Payments)
Rejection Reason: a link to Detail will appear when Claim Status is Rejected at Clearinghouse or Rejected at Payer EDI. Clicking the link will bring up a new page that shows the specific reasons why a claim was rejected by the Payer (ex: Incorrect Billing Address).
If the claim was sent to Office Ally, you will be able to view the entire history by selecting the appropriate file under the new “Files” column and clicking either “Export” or “View”.
- HCFA: A file from the clearinghouse stating they have the claim and have forwarded them for processing. The clearinghouse may reject the claim if it has errors.
- 5010 (an 835 in readable format): shows payment or denial info after Insurance has received and processed the claim.
Clicking View will display the file in a new page.
Clicking Export will direct the user to select where to save. The file will be saved as a .txt file.
Note: If you are using NPAWeb, make sure you are selecting the "Webfile" destination before trying to download the file to your local device:
Charge Lines – Transfer Balance and Post Adjustments
Access Edit Charge Line page
Double-click on a charge line in the Claims Ledger to open the Edit Charge Line window.
The Transaction History section of the Edit Charge Line page will list all transactions made against the charge line, starting with when the claim was submitted, ERAs automatically posted, and the billed Insurance target (Primary, Secondary, or Tertiary).
Any manual adjustments/payments can also be viewed in the Transaction History.
Charge Line Actions
The following charge line actions can be taken:
- Adjustment – Post corrections.
(e.g., partial balance transfer amount or manually entered copay due entered incorrectly). - Transfer Balance – Transfer all the charge line balance to another funding source or to client's responsibility.
- Transfer Partial Balance to Client Responsibility – Transfer a specific amount to client responsibility, typically to bill in advance of the ERA/EOB for copays.
- Settle – Set the balance to zero.
- Rebill – Used to send corrected claims.
- Note – Add any note related to the charge line.
- Follow-up – Set a date and Note for further action needed for the charge line.
All actions posted will be recorded in Transaction History along with the date of the transaction and the user. All action types have an optional note field for comments.
Bulk Update Charge Lines
To apply the same action to multiple charge lines at one time:
- Select the charge lines to be updated with the checkbox in the Claims Ledger grid
- Click on Bulk Update Charge Lines
- Select the action and click Post
Edit Charge Line Actions
Actions can also be applied individually via the Edit Charge Line page.
Action: Insurance Adjustment
The Insurance Adjustment action will display an amount field and a second dropdown with a list of adjustment codes. Codes are searchable via the keyboard number buttons.
Enter an amount, select an adjustment code, enter an options note, and click Post.
To enter a negative amount, select the “-“ key on the keyboard.
Action: Transfer Balance
The Transfer Balance action displays a dropdown with:
- The list of Funding Sources per the client contract’s Add’l Funding Sources order of precedence, and
- Client
When posted, the entire charge line balance will be transferred to the funding source selected or to client's responsibility.
Action: Transfer Partial Balance to Client Responsibility
This action displays a dropdown to select the type of Client Responsibility: Copay, Coinsurance, Deductible, or Miscellaneous.
Select a type, enter an amount, enter an optional Note, and click Post.
The entered amount will be transferred to the selected type of Client Responsibility.
Action: Rebill
When a charge line has been denied by the payer, the user must edit the original claim charge lines in Claims Manager to fix the rejection reason, and then select the Rebill action for one of the denied charge lines.
The Rebill action displays a Note field. Enter a Note, usually the rebill reason, and click Post.
Clicking the Post button will change the Claim Status to Ready for Rebill and the charge Line Status to Pending Insurance for every charge line submitted on the original claim.
When the corrected claim is sent to the clearinghouse from the Claims Manager Claims tab, NPAWorks Billing enters a resubmission code 7 and the original claim number so that the claim does not get denied as a duplicate.
Action: Note
The Note action displays a field for entering comments unrelated to a specific action.
Action: Follow-up
The Follow-up action displays a date when future action is needed and a Note field. Select a date, enter a Note, and click Post. See Follow-up flex report.
Action: Settle
The Settle action displays a dropdown to select an Adjustment Code and an optional Note. Select a code, enter an optional Note, and click Post. The Charge Line status is changed to “Completed”, Claim Status is unchanged, and all current balances are set to $0.00.
Action: Discard Claim
The Discard Claim action will remove a claim from the system. If a denial has been received from the payer, the claim is marked as voided and the void can then be submitted to the payer. If any payments have been posted to the claim and message that all payments must be reversed before the claim can be discarded is displayed. Once successfully discarded, the appointments linked to the former claim can now be edited.
Action: Client Adjustment
The Client Adjustment action will display an amount field and a second dropdown with a list of adjustment codes. This action allows for adjustments to copay, co-insurance, or deductible amounts. To adjust outstanding insurance balances that have been transferred to client responsibility, select the This action will also allow for Misc. Client Discount adjustment code.
View Payment Details from Transaction History
From Edit Charge Line page’s Transaction History it is possible to view payment details.
Select any Payment transaction and select the icon to the left of the date or right-click on the transaction.
Here you will see 3 options for a Payment - Open Payment, Copy, or Copy Reference
When Open Payment is selected, the Edit Payment window will be displayed.
When View ERA is selected, the View ERA page with the payment information for this transaction is opened. This option will be greyed out for manually-added Payments.
The Copy action copies all the selected payment transaction history to the clipboard.
The Copy Reference copies only the Ref # for easy pasting in Payment Ledger filters.