Claim Processing with Override (CMS 1500)

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Add claims and services from CMS billing forms to an open batch. This form also provides users with override capabilities (as defined in User Definition/User Role Definition) the ability to resolve pending claims and approve denied services.

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Prerequisites:

A batch must be created in the Batch Creation form.
Claims must have an open status.

In the Select Batch field, search for and select the batch by name or ID number.

Claim Basics

The Claim ID field displays ID. Claim IDs are automatically assigned to each claim.
The Funding Source field displays the funding source associated with the batch.
In the Member Name Or ID field, enter the member name, and select.
In the Provider field, enter the provider name, and select.
Click Process Report to generate the Valid Authorizations report, which details authorizations associated with the member.

Diagnoses

In the Principal Diagnosis field, enter the diagnosis.
In the 'Diagnosis' fields, enter additional diagnoses as appropriate.

Medical Record

The Federal Tax ID# field displays the provider's tax ID (Provider Registration form), and can be edited.
In the Medical Record Number field, enter the medical records number.
The Current Charges Entered field displays the total claim dollar amount.
The Total Fee Table Amount field displays the total charge for all services.

This value is calculated by adding the service fee amount, and multiplying by the number of units for each procedure code.
If there is no associated amount, 0.00 displays.

In the Patient Paid Amount field, enter the amount paid by the patient.
The Total Expected Disbursement field displays the total expected disbursement for all services under the claim, using their current claims processing expected disbursement calculations.

Member Information

In the Patient Status field, select the patient status.
In the 'Condition Related To' fields, select whether or not the condition is related to the client's employment, an auto accident, or another type of accident.
In the Date Of Current Illness/Injury/Pregnancy field, enter the date when current illness occurred.
In the First Date Of Similar Illness field, enter the date that a similar illness first occurred.
In the Unable To Work From and Through Date fields, enter the first and last dates that the client was unable to work.
In the Referring Physician field, enter the name of the referring physician.
In the Hospitalization From and Through Date field, enter the first and last dates that the client was in the hospital.
In the Outside Lab field, select whether or not lab work was sent to an outside lab.
If Yes, enter the amount of the fees that were charged in the Outside Lab Charges field.
In the Resubmission Code field, enter the code for resubmission.
In the Original Submission Code field, enter the original code.
In the Prior Authorization Number field, enter the authorization number.
In the SSN field, select whether or not the client's social security number was recorded.
In the EIN field, select whether or not the client's employer identification number was recorded.
In the Patient Account Number field, enter the client's account number.
When finished, click Submit.

Additional Section

Service Detail

SQL Table

SYSTEM.batch_claim_lvl_core

► Registry Settings