Processing Claims

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Processing Claims

From the Preview window, you can view and process insurance claims.

 

You can also access the Claim Verify window directly from the Patient Profile screen by clicking on the gear icon for the selected script and choosing the Claim Verify option.

 

Topics

How Do I Process Claims?

Can I Auto-Submit Claims after Filling Scripts?

How Do I Verify Claims?

Can I Print a Report of the Insurance Provider's Response?

How Do I View Explanation of Benefits Records for this Claim?

 

 

How Do I Process Claims?

To process claims for a particular script in the profile, follow the instructions below.

 

You can also create a Workflow stage to submit claims automatically when scripts are filled.

 

1.In the Patient Profile, choose the correct script and click on the Preview Script button.

2.The Preview window should automatically display the latest fill for the script. If necessary, you can locate a previous fill on the left side of the screen and Preview that fill instead.

3.Click on the Options button and select View Claim.

4.The Claim Verify window will appear. This window will show the claim(s) for the script. If claims were submitted to multiple insurance providers, each separate claim will appear in the window.

 

A status bar will appear above each claim to show whether it has been approved, rejected, etc.

 

For each claim, you can perform one of the following actions:

a.Submit (or Resubmit) the claim.

b.Reverse the claim.

c.To add specific insurance overrides, you can click on the Add Override button. This will open a list of override options (e.g., "Other Coverage Code (C8)"). Choose an override, enter the correct override code, and click on the Close button.

d.Submit a Prior Authorization through CoverMyMeds.

e.Fixup a claim that has been rejected (by changing the Doctor NPI, Cardholder ID, etc.).

f.Refresh the insurance information.

 

If you need to edit an insurance provider's information, click on the arrow icon next to the insurance summary. This will flip the insurance "card" and show an option to Edit the insurance record. You can edit the insurance provider's information or the patient's insurance information.

 

5.Once you have submitted the claim to each insurance provider, you can click on the Verify Claim button.

 

More options are available on the left side of the screen to Edit or Flag the script or to Return to Stock. There are also options to Print the provider's response to the claim, view the Price Formula information, or view the Explanation of Benefits records.

 

 

Can I Auto-Submit Claims after Filling Scripts?

You can choose to have insurance claims submitted automatically when you enter new scripts. To do this, you will need to create a Workflow stage to handle these situations. To create an Auto-Submit stage:

 

1.Click on the System menu item.

2.Select Workflow Setup. The Workflow Setup screen will open.

3.Click on the New Stage button.

4.Enter the stage's Name (e.g., "Auto-Submit Claims.")

5.In the Workflow field, search for your pharmacy's Workflow system.

6.In the Type field, click on the drop-down arrow and select "Automatic."

7.Click Save.

8.Next, click on the Requirements tab and then click on Add New.

9.In the Entry Requirement field, click on the drop-down arrow and select the "Insurance (status)" option. (This will ensure that only scripts with insurance will be sent to this stage.)

10.Click on the Save button.

11.Click on the Add New option again.

12.This time, choose "Script Entry" as an Entry Requirement. (This means that scripts will only enter this stage after they have been entered in the filling screen.)

13.In the Grouping field, make sure this requirement has the same grouping number as your "Insurance" requirement.

 

"Grouping numbers" link requirements together. If two requirements have the same number, they work as "and" statements. This means that both of your requirements must be met before a script will be considered eligible for this Workflow stage.

 

14.Click Save.

15.Click Add New again.

16.In the Entry Requirement field, choose "Hold Script (status)."

17.Mark the Not checkbox. (This will prevent Hold scripts from being included in the stage.)

18.Again, make sure the Grouping number matches the other requirements.

19.Click Save.

20.These requirements may be enough to narrow down which scripts enter the Auto-Submit Claims stage. If you need to narrow the list further, you can add more requirements as needed.

21.When you have added all the necessary requirements, click on the Tasks tab.

22.Click Add New.

23.In the Task field, click on the drop-down arrow and select the "Claim Submission" option.

24.Click Save.

25.After this Workflow stage has been created, when a user enters a script with insurance, the claim will be submitted to the insurance provider automatically. You may also want to set up a Claim Verify stage to review the claim after it has been submitted.

 

If you have an auto-submit stage set up but do NOT want to submit a particular script's insurance automatically after filling, you can uncheck the Submit Claim checkbox in the Script Filling screen. This option will be checked by default when entering a script, but can be unchecked to prevent the claim from being submitted automatically.

 

 

How Do I Verify Claims?

After a script has been filled and a claim has been submitted, users can be automatically prompted to verify the claim details. To set up this Workflow stage:

 

1.Click on the System menu item.

2.Select Workflow Setup. The Workflow Setup screen will open.

3.Click on the New Stage button.

4.Enter the stage's Name (e.g., "Claim Verification.")

5.In the Workflow field, search for your pharmacy's Workflow system.

6.In the Type field, click on the drop-down arrow and select "Automatic."

7.Click Save.

8.Next, click on the Requirements tab and then click on Add New.

9.In the Entry Requirement field, click on the drop-down arrow and select "Claim Submission." (This will ensure that only scripts with submitted claims are sent to this stage.)

10.Click Save.

11.Click on the Tasks tab and then click Add New.

12.In the Task field, click on the drop-down arrow and select "Claim Verification." (This will cause the verification window to appear after the requirement is met.)

13.Click Save.

14.Now, when users fill a script with insurance and the claim is submitted automatically, a window will appear asking the user to verify the claim.

 

 

Can I Print a Report of the Insurance Provider's Response?

From the Claim Verify window, you can do all the things discussed above; view and edit the claim information, submit the claim, reverse it, etc. If you need to print a copy of the insurance provider's response to the claim, you can click on the Print Claim Response option.

 

 

How Do I View Explanation of Benefits Records for this Claim?

You can view EOB records for this claim by clicking on the Explanation of Benefits button on the left side of the screen. (The button will toggle between Explanation of Benefits and Claims. You can click on the Claims button to return to the claim view.)

 

See Also

Entering Insurance Information

Prior Authorization

Workflow Setup

Explanation of Benefits