To submit a new claim, follow the below:

Step 1: From the Claims list, select Provider – Direct Submission.

Step 2: The screen will display as shown below. Look up the member for which you want to add claim for, using Member ID or Last Name, DOB and HealthPlan, by adding details in search and clicking on search icon.

Step 3: Once you have the member record in result field, click on Submit claim button at the left-hand corner of the member record.

Step 4: Once the button is clicked, system will re-direct to the screen to add claims. Please refer to the image on next page of how the screen will look now. There is a total of 10 sections to fill the details.

Step 5: Below are the steps to add details on the claim:

Add Authorization number on the claim. You can click on the magnifying glass to look up an authorization from the system. Click on the Auth# to select the auth for this claim.

Basic member information will automatically populate, based on the member we selected initially before we clicked Submit Claim

Under Provider Information section, you can choose the rendering provider for the claim. Provider can be selected using two options

Provider ID search using magnifying glass, to look up provider using filters. Once you have the provider in result grid, click on the ID to select the provider.

Select the Provider drop down. which will show you all providers under your organization.

Once you have selected the provider, all other details will be auto- populated.

If you wish to change the specialty of the provider (In case the provider is multi-specialty), click on the specialty drop down.

If you wish to change the organization (Billing entity) you can click on the drop down to choose from different organizations linked to this provider.

Addresses – Billing, Service and Pay to

If the provider has multiple offices, users can select the correct office from the dropdown menu.

Additional Information section will let you add additional details on this claim like

Patient Account #

Patient paid amount

Purchase service amount

Claim Details will let you enter the POS of this claim.

When the POS added is an inpatient POS, it lets you add the admit and discharge date.

Note: In case of inpatient claim, it is mandatory to add Admit date.

When the POS is Ambulance, the ambulance icon gives you pop up to add ambulance details. Fill in the details and click on OK to save the ambulance details.

Diagnosis field lets you add 12 distinct diagnosis on the claim. You can either type in the diagnosis code (Tab Out) and hit add OR you can look up the diagnosis code using the magnifying glass.

Services lets you add all the details for procedures to be billed on this claim.

Below are the details you can add on the service line

Service From and Service To date and time. (Advised to add time for Anesthesia claims)

Service code/Procedure code. You can type in or look up from the magnifying glass icon. Click on the code to add on claim.

Step 13: The second information tab is Additional Details. Within this tab, three more sections will appear.

Step 14: The first section is Documents. Users can upload and attach documents to the referral request. Users are also able to fax documents to the organization. To upload documentation and submit it electronically with the referral request:

Select the Category and Priority of the document.

Click Browse to find the file from the computer directory

Upload documents in the following formats: .doc, .docx, .xls, .xlsx, .pptx, .xps, .psd, .htm, .pdf, .tiff, .rtf, and text.

Click the Add Additional Documents button to add multiple documents.

Once users click Save, the document will send with the referral automatically.

Step 15: After verifying the data entered, users can save the request.

To submit the referral request, click Save.

To submit the referral request and add another request for the same member, click Save and Add for Same Member.

Note: When an authorization or referral request is submitted, users will receive a notification detailing the authorization request number with the status. Then on the Authorization screen, the recently submitted authorization number will be displayed automatically on the header portion.

Step 16: Users have the option to Print Auth on the lower section of the screen once it is saved. This feature allows users to print authorization requests. The popup window gives options to print and export the request.

Export Options: There are several options that the reports can be exported to:

Crystal Reports (RPT)

PDF

Excel 97 – 2003

Excel 97 – 2003 Data Only

Word 97 – 2003 Editable

Word 97 – 2003

Rich Text Format (RTF)

Character Separated Values (CSV)

XML