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Claims Workflow

Cassia Carrena Harsha
  • Updated

This section outlines the complete end-to-end workflow for creating and submitting claims using the Claims Module.

Step 1: Create a Service Authorization

  1. Navigate to the Service Authorization form from the case forms tab.
  2. Enter the required details including:
    • Service
    • Provider
    • Payer / Contract
    • Authorized Units
    • Start Date and End Date
  3. Save the Service Authorization.

Once saved:

  • The authorization becomes active in the system.
  • If the current date falls within the authorization date range, it will appear in the Case Detail page grid.

Step 2: Verify Service Authorization on Case Detail Page

  1. Open the relevant Case Detail page.
  2. Review the Service Authorization grid.
  3. Confirm that the correct service, provider, dates, and remaining units are visible.

Note: Expired authorizations will not appear in the grid but can still be used when filling Case Notes.

Step 3: Complete the Case Note Form

  1. Open the Case Note form for the case from the case forms tab.
  2. Enter the Service Date.
  3. Select the Provider, Contract, and Service Code and other required fields.

System behaviour:

  • If a valid Service Authorization exists for the service date:
    • Authorization Number is populated in Authorized Service
    • Auth Status is set to Approved
    • Remaining Qty of Units is displayed
  • If no valid authorization is found or units are exhausted:
    • Authorized Service shows Pending
    • Auth Status shows Pending
    • Remaining Qty of Units remains blank

Step 4: Enter Units in Case Note

  1. Enter units in one or more of the following fields:
    • Billable Units
    • Pending Authorization Units
    • Unbillable – Non-billable Units

Validation rules:

  • At least one unit must be entered.
  • The form cannot be saved if all unit fields contain zero.
  • If status is pending, then billable units cannot be entered.

Claim outcomes:

  • Billable Units only → Claim created with Ready status
  • Pending Authorization Units only → Claim created with Pending Authorization status
  • Billable + Pending Authorization Units → Claim created with Pending Authorization status (two service lines)
  • Unbillable – Non-billable Units only → No claim created

Step 5: Review Pending Claims

  1. Navigate to Claims Module from the hamburger menu.
  2. Open the Pending Claims grid.
  3. Review claim status (Ready or Pending Authorization).
  4. Use the eye icon to view services and associated authorizations.

Step 6: Submit or Void Claims

  1. From the Pending Claims grid:
    • Submit claims internally or externally
    • Void claims if needed (voiding does not delete forms)
  2. Once submitted:
    • Associated Case Notes become read-only

Submission behaviour:

  • Internal submissions allow manual payment capture
  • External submissions are batched and sent to MNITS via Planstreet Function App

Step 7: Track Submitted, Batched, and Paid Claims

  1. View submitted claims in the Submitted Claims grid.
  2. Review batch details in the Batched Claims grid.
  3. Review payments in the Payment Claims grid.

Step 8: Reporting and Export

  1. Navigate to the Dashboard.
  2. Open the Claims Reports section.
  3. Apply filters as needed.
  4. Export results as a CSV file.

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