Step 4: Chapter 5 - Claim Entry for Rocky Shore, West Point, Sunset Springs, Maple Hills, Hidden Cities, Harbor Lake (CMS-1500 Form)

 Training Video

After completing the Patient Registration section, the next step in the patient visit process is Claim Entry.  Post all charges contained in the Claim Entry section of the workbook .   

Following are the page numbers for each Claim Entry section:

 Rocky Shore, pg 75   West Point, pg 49 
 Sunset Springs, pg 53Maple Hills, pg 83
Hidden Cities, pg 57 Harbor Lake, pg 45  


Select the Claimto enter each encounter form (claim).   

Type of Claim, New or Existing?

It is important to know the difference between creating a new claim versus updating an existing claim.

Search Claim by Name: Place your cursor in this field and type in either part of or the full patient first or last name. The results will filter all patients with these specific characters found in the database and display them alphabetically in an organized table.  Always search here first to determine whether patient and claim are already in the system to prevent duplicate claim entry.  All saved claims will display here.

Add Claim: Click this button to begin adding a new claim.

Review the Tabs

There are nine tabs across the top of each claim.  The first three tabs contain all the necessary information to complete the CMS-1500 form.

The nine tabs and descriptions are:

1.     Claim: Contains rendering, billing, and referring provider; facility and insurance information; and claim authorization #.

2.     Charges: Enter ICD codes, CPT codes, and all relevant charges and payments.

3.     Additional InfoEnter accident information, hospitalization, unable to work, and last menstrual period dates.

4.     Insurance: View patient’s current payer ID numbers.

5.     Activity: View transactions for this claim.

6.     Notes: Not applicable.

7.     Alerts: Not applicable.

8.     Documents: Not applicable.

9.    Review: Not applicable.


How Many Claims Per Patient?
It is important to verify the number of claims your assignment requires.  This information is located in the third column on the Patient Listing report in the workbook . 

Following are the page numbers for the Patient Listing report:

 Rocky Shore, pg 4   West Point, pg 4
Sunset Springs, pg 4 Maple Hills, pg 4
Hidden Cities, pg 4 Harbor Lake, pg 4  

Add a New Claim to a Patient
Before assuming you need to Add a claim, it is important to verify the number of claims your assignment requires.  (see the previous

To add a claim into the system, click the Add Claim button. Next, click the Blank Claim or the Add for Patient Name button.

1.  If you click the Blank Claim option, you must immediately click the Select Patient icon and search for the desired patient.


2.    If you click the Add for Patient Name option, the active patient that is displayed at the bottom left of the software, will populate in 1 Claim tab.

                                                                                                   Active Patient

Find an Existing Claim

You can retrieve an existing claim to fix errors.  To find a claim, click the Find button or Find for Active Patient button.

Place your cursor in the Search field and type in either part of or the full patient’s first or last name. The results will filter all patients with these specific characters found in the database and display them alphabetically in an organized table. Always search here first to determine whether the patient and claim are already in the system to prevent duplicate claim entry. All saved claims will display here. Click the Search button.

1 Claim Tab

Once a patient is selected, most of the previously entered patient information will default here. Double check the information that does default, and complete the remaining fields.                                                                                                                                                           * Should be defaulted from the initial Patient   entry.                                                                                                                                     ** Needs to be completed with claim information provided in the workbook .

    1.      Claim #: Auto-fills.

    2.      Claim Complete: All claims will be checked as “Claim is complete,” unless when you click to Save the claim, an information screen              informs you that this claim is incomplete and asks if you would like to continue to save as “incomplete.” If you choose to save your                 claim as incomplete, you must remember to get the correct information and enter it in the incomplete/incorrect claim, and then                     check the box to make the claim complete before saving. A claim that is not complete results in a score of 0 (zero).

    3.    *Select Patient: When adding a new claim, you will need to search for your patient here. Once selected, the defaults from the                     patient registration process will populate.
    4.     *Select Rendering Provider: A provider will default if already entered in Patient , 4 Claim Defaults tab. Listed at the top of the            encounter form is the provider who is treating the patient.

    5.     Select Billing Provider: This field will default from the rendering provider field.
    6.     **Select Referring/PCP Provider: A provider will default if already entered in Patient , 4 Claim Defaults tab. You can also                    select it here by clicking Search. If you need to add a provider, see page 150. 

    7.     **Select Facility: If a provider mainly sees patients at a clinic, but happens to perform procedures at a facility, the facility is
            indicated on the encounter form for you to enter here. If you select a facility, you must use a POS (Place of Service) code of
            either 21 or 22 (In-Patient or Out-Patient, respectively) when completing the 2 Charges tab.
    8.     *Select Primary/Secondary Insurance: If the payer information does not default here, then return to Patient and complete                 the required payer information in the 3 Insurance tab. Before saving any updated information, be sure to remember to check the                 box at the top of screen to update all saved claims, and then click Save. Screens of this field can
be referred to on pages 32 and 40.

    9.      CMS-1500: The specific claim type.

    10.      **Authorization #: If an authorization number is given on the encounter form, enter it here. You MUST also click
               the Copy Authorization to Claim button.

2 Charges Tab

Next, enter the ICD (diagnostic codes), Dates of Service(s), POS, TOS, CPT, Modifiers, Unit Price, Units, Total Charges, and Payment made in the office at the time of the visit.  Press Tab on the keyboard to continue to the next field.  Screen fields and their descriptions are as follows:

1.     ICD #: Enter the ICD (diagnostic) code [including a period (.)].

2.     Set Rows: Set the number of rows to the number of procedure codes you need to enter.

3.     From / To: The “From” date of service and “To” date of service.

4.     CPT: Enter the charge code that indicates the procedure performed.

5.     POS: Place of Service; click the Search icon for selection. It defaults to 11 for office, but if you have chosen a facility under         the Claim tab, you will choose POS 21 or 22 (In-Patient or Out-Patient, respectively).

6.     TOS: Type of Service; click the Search icon for selection. It defaults to 1 for medical care, but ultimately your                               selection must relate to the section in which the procedure code is found in the CPT manual.

7.     M1, M2, M3, M4: Means Modifier 1, Modifier 2, etc. You can enter up to 4 modifiers per charge.

8.     D1, D2: Means Diagnosis Pointer 1, Diagnosis Pointer 2, etc. The number of D columns that display should match the number         of ICD codes entered above.

9.     Unit Price: Enter the price of the procedure.

10.   Units: Enter the number of times this CPT code is performed.

11.   Total Charges: Auto-calculates to equal the unit price multiplied by units (unit price x units = total charge).

12.   Status: Defaults based on if the payer is electronic or paper. The status will automatically update as the claim is                                 progressed through the revenue cycle.

13.   Copay: Amount and method to be entered if copayment made is indicated on the encounter form.

3 Additional Info Tab

Sometimes important boxes on the CMS-1500 form need to be completed, and these fields are under 3 Additional Info tab. Notice
the fields are indicated by their corresponding box on the CMS-1500 form.

The most common boxes to complete under this tab based on the information on the encounter forms are:

Box 10: Accident information is set to “No,” but if it is “Yes,” you must indicate that here. If it is an auto accident, you must indicate
the Accident State, which means the abbreviations of the state in which the accident occurred. If you choose “Yes” to one of the
three types of accidents (employment, auto, other), you must also complete Box 14 (date of accident).

Box 14: Date of Onset of Illness or Accident (or Injury).

Box 16: Date unable to work; “From” and “To” dates.

Box 18: Hospitalization dates; if the current claim is a result of a prior hospitalization, enter the dates here.

Last Menstrual Period: Date (box 14).

4 Insurance Tab

This screen provides the opportunity to view any insurance information.


5 Activity Tab

The Activity report lists the activities for all charges on this claim only. This is a good way to confirm postings (both charges and
EOBs) and aging.

Click the List Activity    button . The report will display for you to view or Print this activity report.

Save Your Work and Print the Claim
After completing the 1 Claim tab, 2 Charges tab, and 3 Additional Info tab, it is time to save and/or print the claim. 

Two ways work for the classroom environment:


If you don’t want to Save your work, click the Close button.  

Practice Revenue Cycle Activities: Claim Management

The practice revenue cycle activities are a combination of discussion questions and activities using ClaimGear  and its workbook.

It is important to complete the claim entry task correctly and efficiently. After you have generated the claims as required, complete the following tasks to further enhance your revenue cycle experience as it relates to your current ClaimGear  assignment.

1. Did you realize in the office setting, either the receptionist, nurse/medical assistant, or biller could potentially enter in the claim? 
a. What are the pros and cons of each for this assignment? 
b. How does having ClaimGear  online benefit the claim entry process?
c. Which future position are you interested in?

2. How many patients in this assignment made a payment at the time of service (financial information is printed at the bottom of the claim ticket)? 
a. Were you able to apply this at the time of claim entry? Or did you forget? 
b. Do you think collecting the co-payment at the time of service is important? Why or why not?

3. How many patients were seen because of an accident?

4. Based on the claims submitted, were the appointment types and procedures scheduled with adequate provider time? Review your appointments against the claims and determine if whether changes to the lengths of appointments are needed.

5. How many patients had an insurance authorization number?

6. Create an alert for a couple of patients. Is this function useful in this type of office?

7. Which payer did you send the most claims too? (Generate report Misc Reports, Payer Listing by Usage.)

8. Interested in viewing the claim details you entered? (Generate the report Claim Reports, Claim Details.)

9. When a patient is leaving the office after he has been seen by the provider, claim entry can quickly be entered by several employees. You have the ability to print an Activity report from either the Patient or Claim section. This can also be used as the receipt had the patient made a co-payment in the office. Print an activity statement for a couple of patients.

10. The claim review process and claim submission process is simulated through an electronic claims scoring. The goal of the biller is to submit claims electronically and the first time to have it all correct without any rejections. a. How many claims did you receive 100% of when you scored the claim for the first time? b. How can you improve your claim entry? Suggestions for improvement include becoming more efficient, taking more time to do the job correctly, and understanding the process better or understanding the software fields better.