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Module 2: Claim Submissions & Management

As a US Biller, there are 5 learning modules for you to walk through before you get up and running with Jane’s insurance features:

Learning Modules Complete
1. Setting up insurers, billing codes, and billing info 🥳
2. Claim submissions & management ✍️
3. Modifiers, creating a custom billing code, changing and adding billing codes
4. Remittances
5. A/R tracking (aging claims)

 

💡Jane Tip: We recommend heading over to Jane’s Demo Clinic to practice as you learn! If you’re a current Jane user, you can find the login information by clicking the Need Help? Button in your account. This password is updated every Monday.

If you haven’t signed up with Jane just yet, you can find the login password by heading to the Jane Community Group on Facebook and clicking the Featured tab. You can also request the password by emailing [email protected].

We always recommend using the demo clinic for testing and practice so that your own account stays nice and tidy. ✨


Module 2: Claim Submissions & Management

Alright, now that we’ve gotten through the basics of getting the clinic set up for submitting insurance, it’s time to take a look at actually submitting the claims and the differences between electronic and paper submissions.

Feel free to scroll through the guide, or hop to a specific section below:


Claim Submission Folders

 

All insurance claims are managed under the main “Billing” tab in Jane.

The “Claim Submissions” area, found on the left, has several folders to keep all patient claims accounted for during the submission process.

Let’s get to know a few of the Claim Submission Folders:

  • The Draft folder is an optional folder used for reviewing claim information. You can set up your account so that all new claims start here. This folder can be helpful if you have dedicated billing staff who need to easily know which claims have been finalized (i.e. all billing codes have been entered) and are ready to be submitted. When your draft claims have been finalized, they can then be moved to the Unsubmitted folder by the practitioner.
  • The Unsubmitted folder holds all insurance claims ready to be submitted. This is where you go to submit claims through our Claim.MD integration, or to generate electronic claim files to upload to Office Ally, TriZetto, or Availity.
  • The Submitted folder holds any claims that have been submitted, and are awaiting remittance from the insurance company.
  • The Approved folder is your “Done” folder! It holds all claims that have received a claim response and there is no additional outstanding amount from the insurer.
  • The Waiting on Primary folder holds any secondary claims that are awaiting primary claims’ adjudication. These secondary claims will automatically move toward your Unsubmitted folder (or Draft if you use this as your review area) once the remittance for any relevant primary has been recorded.
  • For Integrated Claims with Claim.MD customers, the Rejected folder displays claims that have been rejected by Claim.MD or the payer. You can see the rejection reason(s) in the Claim Summary panel.
  • Can’t find a claim? Use the Search function.

Integrated Claims, CMS-1500s & EDI 837ps - What’s the Difference?

Integrated Claims

When integrated with Claim.MD, you can submit claims directly from Jane. No need to download claim files and upload them manually in Claim.MD– Jane is your 1-stop shop here!

EDI 837p

Electronic Data Interchange (EDI) is the electronic exchange of business information in a standard format. Simply put, EDI is how different entities send and receive large amounts of data efficiently. These files are used for electronic submission through clearinghouses, in our case you can submit an EDI created by Jane to these clearinghouses:

CMS-1500

CMS-1500 is the standard paper claim form used to bill insurance for rendered services and supplies. It provides information about the client, their corresponding insurance policy, and their diagnosis and treatment. This information is the same that’s included in the EDI file, just organized for human eyes to read, as opposed to a computer.

If you do choose to go with paper submission, or even if you just need to understand where certain information is populating from in Jane, we’ve created this handy reference sheet for you to use: CMS-1500 Reference Sheet.


Submitting Claims through the Claim.MD Integration

To submit claims electronically, let’s head to the Billing Tab and select the Unsubmitted (or Draft) folder. From here, select the claims you’d like to submit.

Next, click Submit Selected Claims

From here, Jane will do a quick health check of these claims to make sure the relevant information is here. If you forget any key pieces of your claim (like CPT codes), Jane will flag the claim for correction:

Once your claims are ready to go, you can click Submit X Claims to Claim.MD button, at the bottom of the page:

Aaaaand, you’re golden 🎉

These claims will be sent directly to your Claim.MD account for submission, and will be visible there within an hour.

💡Did you know that, if you’re using Claim.MD, you can also complete eligibility checks right in Jane? Check out our guide on Eligibility Checks for more.

Not yet using Claim.MD? Check out our guide on Integrated Claims along with some frequently asked questions. to learn more and get started.


Generating an EDI File for Claim Submission

 

If you’re submitting to Office Ally, Trizetto, or Availity; this is for you 👋

The process to generate an EDI for submission is similar to that of integrated claims:

  • Head to the main Billing tab > Unsubmitted folder
  • Select the claims you’d like to include in your batch.
  • Click the Submit Selected Claims button at the bottom of your screen and continue to the Pre-Submission Checklist.

  • Once all the fixes are made, then you can generate your EDI file.

  • Click the blue Download button once to download one EDI file that includes all of these claims/dates of service and then upload this file to your clearinghouse account.

And voilà!

You can now take this EDI file to your clearinghouse and upload it to complete the submission process.

All submitted claims will now be moved from the Unsubmitted folder area, over to the Submitted folder awaiting payment.

Practice Drill 🏈

Hop on to the Demo Clinic to do this next exercise!

Instructions:

  • Head into the Billing tab at the top of Jane and then select the Unsubmitted folder.
  • Select a claim by clicking on the item, highlighting it blue.
  • Click the Submit Selected Claims button at the bottom of your screen and continue to the Pre-Submission Checklist.
    • Fix any errors (marked by red boxes) that pop up on the submission by clicking Edit beneath the notice.
  • Once the claim is ready for submission, continue to Generate Submission for 1 Claim.
    • Note that the claim will now be moved to the Submitted Folder once this is done.

Touchdown! 📣


Resubmissions & Corrected Claims

If you need some help resubmitting a corrected claim, either with Jane’s integrated claims or EDI feature, we’ve included this handy guide doc for you here: Managing Resubmissions & Corrected Claims.

Pro tip: If you’re connected with Integrated Claims, you’ll see rejections come straight into your Rejected folder. You’ll be able to fix up your claims from there for a speedy resubmission process.

As always, if you’d like to read further on creating and submitting claims or generating EDI files in Jane, we’ve put together a very handy resource guide you can view in Step 5 of our US Insurance Billing Training.


CMS1500 - Health Insurance Claim Form

 

Jane can generate a CMS1500 form into an editable PDF for paper claim submission.

Once you have Arrived an appointment and have added in all insurance claim information, you can click the downward arrow next to the “Pay” button and select Generate CMS1500:

From the Draft or Unsubmitted folder, you can also generate a CMS1500 form by clicking the right side arrow, and selecting View Purchase. Jane will tell you if there are any missing fields and then generate the form:

This form can now be Printed, or edited further if required. For editing, it’s best to Save the form first and then make any needed edits to the downloaded copy.

The CMS1500 Forms will print best on blank paper. Some Payers can’t process the claim if it is printed in black and white, so printing in color is generally a good idea.

📍 Note: SOF stands for Signature on File. This is an accepted term but feel free to remove this if you are printing and signing.

Need a little help figuring out what’s supposed to go into each box (and where that info is coming from in Jane)? Check out Start Billing 4: Claim Management & CMS1500 Forms or take a look at our guide on Insurance claims and the CMS1500 or our CMS1500 Reference Sheet.

Batch CMS1500 Forms

Want to export multiple CMS1500 forms in one go? If so, check out the following guide: Generating a Batch: CMS1500s.

Practice Drill 🏈

Hop on to the Demo Clinic to do this next exercise!

Instructions:

  • Head into the Schedule tab and select an appointment on the schedule with insurance attached.
    • You can easily find which appointments have insurance attached by the briefcase icon on their appointment.
  • Arrive the appointment and select the dropdown menu next to Pay
  • Click Generate CMS1500

Touchdown! 📣


Excellent! 🥳 Now that we know how to generate our submissions, let’s head on to Module 3: Modifiers, creating a custom billing code, and changing & adding billing codes.

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