This is lesson 4 of 9 in the US Insurance Billing training:

Billing Lesson	Lesson Complete
Patient Insurance	🥳
Adding Billing Codes to a Visit	🥳
Managing Insurance and Patient Responsibility on a Visit	🥳
Claim Submission Folders	✍️
Claim Submission	☐
Managing Rejections	☐
Posting Insurer Responses	☐
Resubmissions	☐
Accounts Receivable	☐

In this lesson, we’ll cover the following Claim Submission topics:

• Claim Submission Folders
• Claim Summary

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Claim Submission Folders

You’ll manage all insurance claims under the main Billing tab, in the Claim Submissions section.

There are several claim submission folders to keep all patient claims accounted for during the revenue cycle. Let’s get to know the claim submission folders:

• Draft: An optional folder for reviewing claim information. You can set up your account so that all new claims start in the Draft folder. The Draft folder is handy if you have dedicated billing staff who need to know at a glance which claims are ready for submission (i.e., all billing codes have been entered). When your draft claims are ready, move them to the Unsubmitted folder for your biller to submit.

• Unsubmitted: Holds all insurance claims that are ready for submission. New EDI (electronic claim) files are generated from the Unsubmitted folder.

• Submitted: Holds any claims that have been submitted and are awaiting remittance from the insurer.

• Response Received: Holds any claims that have a linked claim response in the Remittances folder and are awaiting review. Once the remittance is reviewed, claims automatically move to the Approved folder if there aren’t any outstanding insurer balances or resubmissions needed.

• Approved: Your “Done” folder! It holds all fully reconciled claims.

• Waiting On Primary: Holds any secondary claims that are awaiting primary claim adjudication. These secondary claims automatically move to your Unsubmitted folder (or Draft, if you use it as your review area) once the remittance for the related primary claim has been recorded.

• On Hold: Use the On Hold folder for any claims that need additional review. Claims don’t move to On Hold automatically, so move them there yourself for follow-up.

• Rejected: If you have the Claim.MD integration and the clearinghouse or insurer rejects a claim, the claim lands in the Rejected folder. Once you’ve fixed the rejection, move the claim back to the Draft or Unsubmitted folder for submission.

• Partially Paid: When you record a partial insurer payment, move the claim to the Partially Paid folder. The claim stays in Partially Paid until it’s fully reconciled.

• Search: Your go-to spot for finding any insurance claim, no matter which folder it’s in. Search by patient name, invoice number, or both, and use the filters to narrow your search.

🩵 Jane Tip: To use the Draft folder as a review area, go to Settings > Billing Settings > Set New Claim Submissions As… and select Draft from the drop-down menu.

Claim Summary

To dive deeper into a claim, go to Billing > Claim Submissions > [folder name] and click View beside the claim to open its Claim Summary.

📣 Heads up: The Claim Summary panel opens only when you click View from a claim submission folder (Billing > Claim Submissions > [folder name]). Clicking View from Billing > Insurer Invoices > [insurer name] opens the purchase page instead.

The Claim Summary panel shows you everything you need to know about a particular claim. Here’s what you can see:

• Claim: The insurer and claim number, patient, staff member, and appointment details
• Billing: The invoice status, amount billed, amount expected from the insurer, and amount expected from the patient or other insurers
• Billing Codes: The billing and diagnosis codes on the claim, with an Edit Billing Codes button
• Submissions & Acknowledgements: Past submissions for the claim, with a Submit Claim button
• Responses: Linked insurer responses, with an Upload ERA button
• Related Claims: Any linked primary or secondary claims, with a View Purchase link

To dive even deeper, click the drop-down arrow beside Claim at the top of the panel for more options:

• View and print: View Policy, Edit Policy, View Invoice, View Purchase, and Print Invoice
• Move the claim to another folder: Mark as Submitted, Mark as Draft, Mark as Rejected, Mark as On Hold, Mark as Approved, and Mark as Waiting On Primary
• Record a payment: Pay & Approve and Record Payment in Detail…

The Mark as options change based on the folder the claim is currently in.

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Continue to Insurance Billing 5: Claim Submission

📘 Continue learning the insurance billing workflow in Insurance Billing 5: Claim Submission, or jump back to the US Insurance Training Hub.