Enter or edit a claim

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What this is for

The claim screen is where a claim is created and corrected: who it is for, which insurance pays, the providers, the diagnosis codes and the line items that make up the charges. After the first save it also shows the claim's transactions, statement, documents, follow-up notes and history.

Two ways of working

Practices work one of two ways. Some enter the encounter (the visit) first, check it, and only then create the claim from it. Others enter the claim directly. Both end on the same claim screen.

The visit happens

Appointment, check-in, exam, plan — usually in the practice's EHR. The provider marks the visit as billable.

Encounter first

Enter the encounterEncounter → Manage Encounter, or imported from the EHR

Check the encounterCodes, providers, insurance and eligibility — the practice's scrubbing

Clean?

No — fix it and check again. It stays work in progress.

Yes

Create the claimEncounter → Create Claim by Encounter: Create Claim for one, Create Claim for Selected for many

Claim directly

Add a new claimClaim → Manage Claim → Add New Claim

Pick the patientThe claim opens, filled with the patient's defaults

Enter the claimInsurance, providers, diagnosis codes and line items — the steps below

Review and Save the claimOn this screen

Send it to the payer — EDI or paper

Before you start

The ways into the claim screen:

To	Do this
Create a claim from one encounter	Encounter → Create Claim by Encounter, then Create Claim on the encounter. The claim opens filled in from the encounter — check it and Save. An encounter that already has a claim says This encounter is already billed.
Create claims from many encounters	In Create Claim by Encounter, search for the encounters, then Create Claim for Selected. It uses every encounter the search found (up to 1000) — there are no check boxes. A Create claim screen shows the count and an Error List first; nothing is created until you click Create Claim there — and then only for the valid encounters.
Enter a new claim directly	In Manage Claim, click Add New Claim and pick the patient.
Start from an existing claim	In Manage Claim, click Copy and create New Claim on that claim. Everything is copied except the Service Date and Entry Date, which you fill in.
Edit a claim	In Manage Claim, click the Claim #, then Edit claim on the Claim Summary. It opens in its own tab.

A new claim starts filled in for you: today's date as Service Date and Entry Date, Place Of Service 12 (Home — change it to 11 for an office visit), the next claim number, the practice's default billing provider, rendering provider and facility, the patient's diagnosis codes, and the patient's first insurance profile. Check each one — they are starting points, not answers.

If you do not see Add New Claim or Copy and create New Claim, your role does not have the right to add claims. Ask your administrator.

Steps: enter a new claim

1. In Manage Claim, click Add New Claim and pick the patient.
2. Under Insurance Profile, choose the Profile. It fills Primary Insurance and Secondary Insurance. Add the Authorization # or Referral if the payer needs one.
3. Under General Information, check Billing Type (HCFA for professional, UB for institutional), Service Date, Claim Responsibility (Insurance or Self Patient), Place Of Service and Transmission Queue Type (EDI, Paper or None).
4. Under Facility and Provider, check the Facility, Rendering Provider, Referring Provider and Billing Provider. Press F1 in a field to look one up.
5. Under ICD Information, enter the diagnosis codes, starting at Code 1. Press F1 to look one up, or click a code under Most Common ICDs.
6. Under Line Items, enter one line per service: the procedure Code (F1 to look up), any modifiers M1–M4, ICDs, Units and Price. Or click Macro to add a saved set of lines.
7. Click Save at the top right. You see Data Saved Successfully, and the claim number shows in the header.

To edit a claim, open it with Edit claim, change what you need on any tab, and click Save. There is one Save — there is no Save and Close.

The General Information tab

The tab is laid out top to bottom:

Section	What is in it
Patient Information	The patient's ID, name, gender and date of birth. Read-only — click the ID to open the patient.
Insurance Profile	Profile (required), Primary Insurance, Secondary Insurance, Authorization #, Referral and Referral #. The ? beside Referral explains each.
General Information	Billing Type, Claim #, Service Date, Entry Date, Claim Responsibility, Batch Name, Claim Type, Place Of Service, Transmission Queue Type and Claim Transmit Queue (which insurance the claim goes to).
Facility and Provider	Facility, rendering, referring and billing provider; resident, assistant, supervising and ordering provider; referral source, ordering facility and Tags.
ICD Information	Up to 12 diagnosis codes, Code 1 to Code 12. Create New ICD Code and Clear All ICDs sit above them.
Line Items	The procedure lines — see below.
Claim Notes	Notes you can pin so they show when the claim is opened. Appears after the first save.

Required on every claim: Profile (for an insurance claim), Service Date, Entry Date, Claim Responsibility, Place Of Service, at least Code 1, and at least one line item.

Line items

Five empty lines are ready when the claim opens. Each line has:

Column	What goes in it
Transmit	Ticked lines are sent on the claim.
Code	The procedure code. F1 looks it up; the Desc fills in by itself.
M1–M4	Up to four modifiers, two characters each.
From Date / To Date	The service dates. They start as the claim's Service Date.
Revenue	UB claims only — the revenue code.
ICDs	Which diagnosis codes this line is for, as numbers: 1,2.
Units	How many. Starts at 1.
Price	Charge per unit. Filled from the fee schedule when there is one.

When you enter a code, the line fills in its description, one unit, the claim's dates, all the diagnosis codes and the fee-schedule price — change any of them.

The buttons above the lines:

• Apply ICD — points every line at all the diagnosis codes entered.
• Add New Item — adds a line.
• Macro — adds a saved set of lines, and fills empty diagnosis codes and providers.
• Remove All — removes every line, without asking.

On each line, More information holds the drug code (NDC), unit of measure and line notes; Transactions opens that line's payments and adjustments; Delete removes the line, also without asking.

Removed lines disappear from the screen straight away, but they are only deleted from the claim when you click Save. On a saved claim, that save also reverses the removed lines' charges.

The other tabs

These appear after the claim is saved for the first time.

Tab	What it is for
CMS 1500 Form Fields	Boxes 14–18 of the paper form. HCFA claims only.
UB4 Form Fields	Admission, discharge, condition, occurrence and value codes. UB claims only.
Claim Transactions	Everything posted to the claim — charges, payments, adjustments — with the balances. Read-only.
Claim Statement	Generate this claim's patient statement, and mark it mailed.
Documents	Files attached to the claim.
Notes	Follow-up notes — see below.
Event Log	Who changed what, and when. Read-only.

Jump to at the top opens the Claim Form View, Claim Statement View, EDI Preview, Event Log and Transmission History. Put On Hold stops the claim from being sent — see Put a claim on hold.

Follow-up notes

There is no separate Follow-up tab: follow-up is the Notes tab.

1. Open the Notes tab.
2. Write the Follow up Notes, or pick a Macro to fill them in.
3. Choose the FollowUp Category — it is required — and, if you use them, FollowUp Type and FollowUp Status.
4. Click Save. The note joins Previous Notes Summary below.

Saved follow-up notes cannot be edited or deleted, so check before saving.

Good to know

A claim stays editable after it is sent or paid

eClaim Pilot does not lock a claim once it has been billed, sent or paid. A change you save changes the claim everyone sees — and saving after deleting a line reverses that line's charges. If a claim has already gone to the payer, check whether it needs a corrected claim rather than a quiet edit.

• Banners at the top tell you something needs attention: the red On hold banner, a Referral problem - this claim may be denied banner, or a note that the claim uses an inactive record (an inactive provider or procedure, for example).
• Pinned Notifications — the pin icon at the top right shows notes pinned on this claim, its patient, providers, payer and codes. It opens by itself when a claim is first opened.

Common problems

You see	Why	What to do
ICD Codes are not in sequence.	A diagnosis slot is empty between two filled ones.	Fill the codes from Code 1 with no gaps.
ICD Codes are not mapped with Line Items.	A line's ICDs is empty.	Enter the pointers, e.g. 1,2, or click Apply ICD.
No Line items entered for this claim.	No line has a procedure code.	Add at least one line.
Units cannot be Empty. / Charges Per Unit cannot be Empty.	A line has 0 or no units or price.	Enter both on every line.
Date of Service cannot be in future	The Service Date is after today.	Correct the date.
Please select insurance for claim transmission.	EDI or Paper is chosen but the profile has no insurance.	Pick a Profile with insurance, or set Transmission Queue Type to None.
Another Claim exists with the same claim Number	The Claim # is already used.	Change the Claim #, or find the existing claim in Manage Claim.
A claim already exists for this patient, date of service, facility…	This visit has already been billed.	Open the existing claim instead — its id is in the message.
Revenue code is required for institutional claim	A UB claim line has no Revenue.	Enter the revenue code on each line.
Selected list contains Billed Encounters. Please exclude billed encounters and continue.	Create Claim for Selected found encounters that already have a claim.	Narrow the search so it finds only encounters without a claim, then try again.
…only 1000 Encounters is the limit for bulk action.	The search found more than 1000 encounters.	Narrow the search — a shorter date range, for example.
This encounter is already billed	That encounter already has a claim.	Open the existing claim from Manage Claim instead.
No Put On Hold or Release Hold button	Your role does not have that right.	Ask your administrator.

Watch it

eClaim Pilot · Billing

Enter or edit a claim

Video coming soon

Related

• Create Claim by Encounter
• Manage Claim
• Put a claim on hold