Step 5: Chapter 6 - Claim Entry For Crown Valley, Cherry Hills (UB-04 Form)

Training Video

https://www.youtube.com/watch?v=Nqd3-P3KCqU


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

 SEE THE “REMINDERS” and “SAMPLE OF CLAIM ENTRY FORM” IN THE WORKBOOK!
 Following are the page numbers for each Claim Entry section:
                                                        
                                                Crown Valley Hospital, pg 49     Cherry Hills Hospital, pg 43

Select the Claim to enter each fee ticket (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 the necessary information to complete your UB-04 form (also known as the CMS-1450 form).



The nine tabs and descriptions are:

        1.     Claim: Contains rendering, billing, operating, and referring provider; facility and insurance information; type of bill; and
                claim authorization #.
         
        2.     Charges: Enter all HCPCS.
        
        3.     Additional Info: Contains statement, admission, and status information. More tabs under this screen enable you to enter
                the diagnosis, procedures, and value code information.
        
        4.     Insurance: View patients’ 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:

                              Crown Valley Hospital, pg 4         Cherry Hills Hospital, 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 information). 

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.    **Type of Bill: With your drop-down arrow, choose 131 (Out-Patient) or 111 (In-Patient) as indicated on your fee ticket.

        4.    **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.                                                                                            
        5.    *Select Attending Provider: A provider will default if already entered in the Patient  , 4 Claim Defaults tab. Listed on the
               fee ticket is the provider who is treating the patient.

        6.     *Select Billing Provider: This field will default from the attending provider field.

        7.     **Select Operating Provider: Complete this field with the provider listed under Procedure on the fee ticket. 

        8.     **Select Other Provider: If there is a second referring physician or second operating physician, select it here.

        9.     *Select Referring Provider: A provider will default if already entered in Patient , 4 Claim Default tab. You can also
                select it here by clicking Search . If you need to add a provider, see page 150.                                                                                           
        10.   Select Facility: This will be blank.
        11.   *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
                check the box at 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.

        12.   **Uncheck “Always auto-calculate totals”: Many units do not divide evenly into the total charge; therefore, deselecting
               this box enables the user to enter in the units and total charge.

        13.   CMS-1450 UB-04The specific claim type.

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



 


2  Charges Tab




Begin this screen by setting the number of rows based on the number of charges on the fee ticket. Then place your cursor in the Service Date field to start entering the claim information. Press Tab on the keyboard to continue to the next field.  

All the following fields are described and need to be completed:

        1.     Set Rows: Count how many charges you will post and enter the number here.
       
        2.     Charges: The sum of all Total Charges for this claim. This amount should match the Total Charges field listed on the fee ticket.

        3.     Service Date: Enter the Service Date.

        4.     HCPCS: Enter the code as listed on the fee ticket. If no code is listed, click to Search all existing charges and a select specific                       charge description.

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

        6.     Rev Code: Auto-fills based on the HCPCS code.

        7.     Description: The description populates for the HCPCS or Rev code, depending on the Use Description From selection.

        8.     Unit Price: Enter the price of the procedure. Remember to uncheck the “Always auto-calculate totals” box under 1 Claim
                tab, especially when a unit price is not available.

        9.     Units: Enter the number of days or times this HCPCS is performed.

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

        11.   Status: Defaults properly based on whether the insurance payer is electronic or paper.





3 Additional Info Tab




Field requirement usually depends on whether your patient is In-Patient (IP) or Out-Patient (OP). This has already been specified
under the 1 Claim tab. See your fee ticket for determining if the patient is IP or OP.




Required Fields for In-Patient Claims

1.     Statement Covered (Box 6): The Statement Covers “From” and “To” dates.

      2.     Admission Date (Box 12): Date of admission.

      3.     Admission Hour (Box 13): Time of admission.

      4.     Admission Type (Box 14): This code indicates the priority of admission.

      5.     Admission Source (Box 15): This code indicates the source of patient admission.

      6.     Discharge Hour (Box 16): The time of discharge.

      7.     Patient Status (Box 17): Select the 01-Routine Discharge.

      8.     Accident/Injury Related to and Accident State (Box 29): Mark the method of accident and enter the state abbreviation in
             which the accident occurred.




Required Fields for Out-Patient Claims

1.     Statement Covered (Box 6): The statement covers “From” and “To” dates.

      2.     Admission Type (Box 14): This code indicates the priority of admission.

      3.     Admission Source (Box 15): This code indicates the source of patient registration.

      4.     Patient Status (Box 17): Select the 01-Routine Discharge




Additional Info Bottom Tabs

You must complete some bottom tabs with the information given on your fee ticket: Diagnosis, Value, and/or Procedure tabs.



Diagnosis Tab




Enter the code or click to Search  for the diagnostic code.   

Field requirement usually depends on whether your patient is In-Patient (IP) or Out-Patient (OP). This has already been specified under the 1 Claim tab.






Procedure Tab

If a procedure is listed on the fee ticket, enter the code and date in the appropriate column. This tab is for in-patient surgical codes only, and it prints in box (FL) 74a-e.




Also listed on the fee ticket when there is an ICD procedure is the operating physician (box 77). If there is an operating physician listed below the procedure, be sure to select this provider under the 1 Claim tab.

 

Value Tab

If the value code and amount are provided, be sure to complete these two fields. The code entered must be two digits.




4 Insurance Tab

This screen provides the opportunity to view and edit 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. 





 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 enjoy experiencing the institutional form?
                a. Create an alert for a couple patients. Is this function useful in this type of setting?
                b. How many times have you logged into ClaimGear  so far? (Generate the report Management Reports, 
                    User Login Report.)
                c. The claim review process and claim submission process is simulated through the 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.
       2.     How many claims did you receive 100% on when you scored the claim for the first time?
       3.     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.