Prepare insurance claims and reconcile payments

Use Insurance > Claims to review claim drafts and payer responses. Use Remittances and Ledger to reconcile payments. These steps apply to workspaces with Insurance enabled.

Before you start

Complete provider and payer enrollment and check the patient’s coverage. A claim needs an encounter, a patient policy, billing and rendering provider details, service information, and diagnoses.

Staff and editors can prepare drafts. A workspace owner or administrator submits claims, uploads supporting documents, and posts or reverses payments.

Encounter billing codes guide documentation and appear on exported notes. Adding those codes does not submit an insurance claim.

Save and review a draft

1. Open Claims and select Create draft. Choose the patient and Encounter. You can also open the claim form from the encounter.
2. In Create claim draft, confirm the policy, rendering provider, service location, service date, and place of service.
3. Review Patient billing information, including the address and each assignment, release, and accident answer.
4. Confirm the diagnoses and service lines. Enter the code, modifiers, units, charge per unit, diagnosis pointers, and authorization number when required.
5. Select Save draft.
6. Open the draft in Claims. Select Edit draft to correct it, or Review submission to inspect the final claim.
7. Resolve the displayed validation errors. Confirm the reviewed version and destination, then select Submit reviewed claim.

The claim records a submission attempt. Submitted means the claim was transmitted; inspect Payer events for acceptance, rejection, or adjudication. Select Refresh status to retrieve the saved status.

Correct a claim or add documents

For a confirmed rejection or setup failure, use Correct or void. The sheet title is Correct or void claim. For a replacement or void, enter the payer claim control number and create the draft for review. A replacement or void requires its own final submission review.

Secondary insurance, Supporting documents, and Prepare hosted appeal are available on Claim.MD claims. They do not appear on Stedi claims.

Use Secondary insurance after reviewing the primary adjudication and policy order. Select the secondary policy, confirm the review, and select Create secondary draft. A denied Claim.MD claim also offers Prepare hosted appeal.

Under Supporting documents, select a PDF up to 16 MB and its attachment type. The claim version accepts up to 10 PDFs. Review the PDF, confirm authorization for payer disclosure, and confirm it excludes separately maintained psychotherapy notes. Select Upload reviewed document, then inspect the saved upload status.

For Outcome unknown, reconcile the claim or attachment receipt before sending it again.

Imported clearinghouse claims live under Imported claims.

Post an electronic remittance

1. Open Remittances. Select the connection and Poll for responses if you need to request new clearinghouse responses.
2. Open an ERA (electronic remittance advice). Review its payment, trace number, claim allocations, adjustments, and patient responsibility amounts.
3. For an unmatched allocation, select Match claim and lines. Match the claim and each ERA line, confirm the review, and select Save match.
4. In Posting preview, enter the verified bank payment reference. Confirm the payment against the deposit or check and review every allocation.
5. Select Post reviewed remittance.

The posted remittance updates claim balances and creates ledger entries. An ERA payment amount requires settlement verification before posting.

Record or correct a ledger transaction

From the claim, select Record transaction. Choose the transaction type and responsible party, then enter the amount, description, reference, and date. Identify a patient copay or an approved overpayment when applicable, and select Record transaction.

For a manual transaction correction, open Ledger, select Reverse entry, enter the reason, and select Record reversal. For a posted ERA correction, open that remittance and use Reverse remittance. Reversals retain the original entries and add linked reversing entries.

Reports summarizes claims by service date. Ledger filters transactions by transaction date. Insurance transaction charges for owners and administrators are on Usage billing.