Claim Document window allows you to search for patient remissions that must be claimed and approved by insurance companies and to attach them to a single claim document that will include information for each one of their encounters. The approved sales receiptscan be billed as a batch by generating the consolidated invoice for the whole batch, thus simplifying the claim request process.

In this article you will find the settings and the summarized step-by-step of this entire module that starts from having pending charges and it finishes when we complete the consolidated invoice for the pending charges.

To start using the Claim Document functionality, you must have the following options configured to start billing for insurance companies :

Any new major insurance companies must be created in Business Partner window. To create a new business partner, follow these steps :

For major companies you must make sure of the following :

In order to give more details about major companies during invoicing processes, you can enter the address of this major company in Address tab. Here you must click on the Edit button next to the Address field :

Notes :
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The business partner group of this major insurer must be Customer in Group Type and have the Is Insurance check active. Is TPA check only applies when this group is a TPA that manages multiple policies from different insurers.

Now, in order to add minor companies to this major company, you must create a Business Partner Group where the code of the group must be the same as the key of the major company. The Is Insurance check must also be active :

Now, you can create minor companies for the previously configured or for any selected major company. This can be performed in the Business Partner window. To create a new minor company, follow these steps :

For minor companies you must make sure of the following :

Notes :

Now that we have both the major and the minor companies, we can create a policy in Insurance Policy Manager.

Here, you must perform a search for the major company (insurer) and in the results click on the dots icon to view more options. Then, select New Policy :

The Create new policy option will open up. Here you must enter the header policy information :

Save the changes.

Now you can add Insurance information for this policy :

Here you can set scenarios of coverage where this policy applies, allowing you to enter maximum limits, approval threshold, follow up limits and coinsurance, deductible, copayment amounts for every patient or for some specific types of patient (e.g. outpatient), for patients inside every service station or just one specific service station and even for products that belong to a specific product class (e.g. drugs).

You can add more details like benefits and diagnostics in this same window.

Now we can assign this policy to a patient.

For this example, we created a test patient record where our patient has the policy we configured assigned so their pre-authorization will depend on the configurations made.

See Insurance information example (Patient Registration window) :

For this example, we generated charges directly from the Encounter charges option in Encounter Dashboard. However these charges can come from services requests, orders, consultations, procedures and more hospital processes that generate charges to the patient encounter and, depending on their approval status, amounts and coverage, they must be authorized or can be rejected for any reason, preventing users to bill them in the Multibilling window.

Creation of charges example :

These charges will go to their corresponding Multibilling extension if the policy is correctly configured.

If the patient encounter is now ready to be billed, you can go to Multibilling window to process the extensions. If this encounter is not closed yet, you will see a confirmation message asking to close this patient encounter :

If the extensions are processed, their sales receipts will now be ready to be billed. However, if for any reason the charges were rejected or are still pending, you can go to Claim Document for their approval and to invoice them as part of the whole batch that will be sent to the insurer.

See Multibilling demo :

If your hospital has accumulated many remmissions that must be claimed to the same insurer, you can go to Claim Document to generate one single claim for these remmissions according to the search criteria that you wish to apply in order to filter the encounters more easily. Here's everything you should know about this window.

Now, in order to create a new claim document, do as follows:

2. To search for the remmissions that will be included in this claim document, you must fill the header details with the search parameters that you wish to apply. The parameters are the following :

3. Click on Search to look for the patient encounters that meet this criteria and that are not billed yet.

Now select the remissions and confirm :

4. These remissions will be attached to the claim document and their totals will be shown in Total field. Save to confirm (it will be saved as a drafted document and the attached encounters can still be excluded if rejected).

See demo :

If any of the attached encounters has more follow-up encounters related that are not billed yet, then these encounters will also be included as a part of the Claim Document.

Now we have a drafted document with all of the attached encounters that we selected. However, these encounters may have issues that caused them to be rejected originally.

If any of these attached encounters has any issues (missing or wrong data, missing documents, etc) then they may be rejected again. In order to allow users to fix these encounters more easily, Cirrus will highlight in red color all those encounters with related issues.

Additionally, if any of the encounters still has their Summary PDF file pending, their status will display No document. If this status appears then the whole batch will not be able to be sent to Nphies. To see how to fix encounter information, check step 3.

To view the issues related to any encounter, click context menu and select Issues log :

You will see the list of issues if there is any : 

Issues found could be related to any of the following topics : 

This is what Nphies validates and having them correctly will help users to get the insurance approval of the charges.

If you have found that the encounter has any related issues, other than the Nphies files attached issue, you can go to Abstracting by clicking on the Abstracting button next to the encounter. If this patient encounter only has the No files attached issue, skip to step 4.

Abstracting allows to fix and validate encounter data, physician data, diagnosis data, coding information and to check the Nphies requests data and the Nphies panel. In our example, our patient was missing their diagnosis so we went to the Diagnosis tab in Abstracting and completed this missing information.

See demo :

If you re-enter the Claim Document you will see how the red highlight disappears, meaning that the issues found were fixed. In our example, our patient still does not have a Nphies file attached, see how to fix this in step 4.

If some encounter or list of encounters still has missing their Summary PDF that must be sent Nphies, you can generate these files in the Create Summary PDF window, that can generate one or multiple Summary PDFs that will be attached to the encounter (they can be generated manually also in Abstracting). 

If any encounter does not have their files attached then they cannot be sent to Nphies for their approval.

To generate these Summary PDF files as a batch, follow the next steps :

Once completed, the encounter status will change from No document to Pending, allowing you to send these encounters to Nphies.

This status change will also apply to the items (charges) attached :
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See demo :

You can view these attachtments in the Electronic Patient Record of this encounter : 

Once that none of the attached encounters has any related issues and that their status is at least Pending, you wil be able to proceed by sending this batch to Nphies for their approval. 

You can still confirm that the encounters have no related issues if you click on the Issues log button, where you must see the following message :

To send this batch, click on context menu and select Send batch to Nphies (see how invoice cannot be generated until the document status changes to Completed) :

You will see the following confirmation message :

Once you have a response from Nphies, you will see this response in the Nphies messages log option (context menu) and in the Items detail option (Status and Adjudication Reason Code columns).

Once the encounters were successfully sent to Nphies, they will appear now as Queued, meaning that no errors were found and now it's time to wait for the approval status to update. If, on the other hand, the encounter shows Error in their status, then it means that some errors were found and you will need to check the Nphies messages log to view these errors.

Note :

There may be some few cases where you will need to exclude some encounters from the document before completing it since they were rejected due to errors. To do so,click on context menu, then Multiple selection. Now, select the encounters to exclude and confirm by clicking on the subtract icon (-).
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If Nphies approves all of the attached encounters, you can now Complete this document, which means that the records to be included may not be edited and that all of their charges will now be  part of the consolidated invoice.

To complete this document, click context menu and select Action Document :

Then select Completed and confirm : 

Now you can generate the final consolidated invoice for the approved totals included in

this claim document. To do so, click context menu and select Generate Invoice :

You will be taken to the Consolidated Invoice window, where you must validate the sales receipts that are going to be included by selecting them and saving the record. Now, you must only select the Detail type of grouping (by category, product class, patient encounter) and complete this invoice by clicking on the gear icon to process.

The consolidated invoice for the charges will be saved locally and it will look as the example below :

Reports:

There are three reports that can be downloaded from this window, each one of the is related to the claim document information, to the list of encounter totals and their status and to the items detail and their status. To see more information about these reports, click on the button :

We hope this improves your Cirrus experience. Remember to share this information and ask for help if you need it.

Date: December 6, 2023.