CLAIM SUBMISSION TOOL

The Claim Submission Tool enables users to submit claim for testing or processing of manual claims.

 

Accessing the Claim Submission Tool

The claim submission tool can be accessed through the Benefit Manager or Customer Service sections of the system.  Both sub-menu includes a Claim Submission Tool option.

When the Claim Submission Tool option is selected, you are brought to the search screen.  From this screen, you can access an existing claim template or create a new one.

 

Claim Search Screen

The claim search screen allows you to search for existing claim templates. The list screen displays the list of templates that are created or updated within the last 15 minutes. The date and time can be modified as required. These standard filters can also be augmented by clicking on the gear to open additional filter settings. 

The additional filter settings are selected by clicking on the + sign.  Any selection with a – will be available on the search screen.

When you have filled out the filtering criteria, click on SEARCH.  The results will be presented.

 

 

EXISTING TEMPLATE OPTIONS

There are three options available for existing claim templates.  You can open the claim, copy the claim, or delete the claim. 

Open Claim

The Open Claim option will open the existing claim template.  Once the claim is open, you will have access to all of the screens.

From this point, you can change the data and submit the claim.  You can also simply submit the existing data.

A couple of notes:

• You can change any and all of the data elements.  If you do not save the record, you will lose the data you changed and the template will revert to its original state.
• You can click on the SUBMIT RAW CLAIM button.  This is populated from the data in the template you have open.  You cannot populate the template with the information in the Submit Raw Claim screen.

Copy Claim

The Copy Claim option allows you to copy the existing template into a new template.  Once created, you will be presented with a copy of the selected claim template.  At this time, we recommend you rename the template as appropriate.

Delete Claim

Selecting the Delete Claim option will delete the claim template.  Once deleted, the template cannot be recovered.

Submit Raw Claim

The Submit Raw Claim allows you to use the Raw claim from either the filled-out template or from the Customer Service claim review.

 

Creating a New Template

To create a new template, click on the Add icon to open a new template screen.  The top of the template has some required information:

The box with “Untitled Claim” is where you will enter the name of the template.  This must be unique.

There is a radial option for Test Claim or Standard Claim. 

• Standard Claim - It is required to choose the option when submitting Manual claims 
• Test Claim - It is used for testing purposes. Test claim are adjudicated based on the actual data but NOT stored as standard claim data.
• Vendor Claim - This is for dev purposes only. Vendor claims are simulation of claims that comes through Relay Health.

Below the list of TABS, which reflects the various segments of the transaction, is the Claim Type.  Your options are Point of Sale (process as if it were a provider) or Direct Member Reimbursement.  

TAB - Basic Information

The Basic Information tab includes the typical required data for a claim. 

Header

The first section is the Header record.  All fields in this section are required.

The BIN number is required and it must be one registered in the switch to process.

NOTES: Two fields can be used for alternative reasons. Processor Control Number (104-A4) is a 10-digit field. Software Vendor/Certification ID (110-AK) is a 10-digit field. If the PCN is required for your group, use the appropriate value.  For groups that don’t use PCN, you can add an alpha/numeric entry.  The Software Vendor field may also be used for entering data.  Users have taken advantage of this to have a reference.  Field Field Name M or Sit Request Field Definition 101-A1 BIN NUMBER M Card Issuer ID or Bank ID Number used for network routing. 103-A3 TRANSACTION CODE M Code identifying the type of transaction. 104-A4 PROCESSOR CONTROL NUMBER M Number assigned by the processor. 109-A9 TRANSACTION COUNT M Count of transactions in the transmission. 202-B2 SERVICE PROVIDER ID QUALIFIER M Code qualifying the ‘Service Provider ID’ (201-B1). 201-B1 SERVICE PROVIDER ID M ID assigned to a pharmacy or provider. 401-D1 DATE OF SERVICE M Identifies date the prescription was filled or professional service rendered or subsequent payer began coverage following Part A expiration in a long-term care setting only. 110-AK SOFTWARE VENDOR/CERTIFICATION ID M ID assigned by the switch or processor to identify the software source. Insurance The insurance section captures the member’s insurance.  Fields with an asterisk (*) indicate a required field.  The exception is the Group ID, which is required.  There is an option to hide some of the additional fields that are not highly used.  Pricing The pricing segment captures the submitted financial information.  The required fields are indicated except for U&C.  As part of the platform, U&C is a required field. For claims that have Other Amount claimed, click on Add Another Row and enter the information as appropriate: The valid qualifiers include: 01 – Delivery Cost 02 – Shipping Cost 03 – Postage Cost 04 – Administrative Cost 09 – Compound Preparation Cost Submitted Claim The Claim section has the product information for the claim.  The Prescription Origin Code is a required field.   Prescription Origin Code options:  0 – Not Known 1 – Written 2 – Telephone 3 – Electronic 4 – Facsimile 5 – Pharmacy If your claim has Procedure Modifier Code(s), click on the Add Another Row, and enter the appropriate information. If your claim has Submission Clarification Codes, click on the Add Another Row, and enter the appropriate Submission Clarification Code.  See the NCPDP ECL code list for the supported options. TAB – Patient The Patient Segment has the information identifying the member for who the claim is for.  When opening the tab, the INCLUDE PATIENT SEGMENT defaults to NO.  To include the segment on the claim submission, click on the YES radial option. TAB – Prescriber The Prescriber tab is where the prescriber information is captured.  To include the segment on the claim submission, click on the YES radial option. TAB – Pharmacy Provider The Pharmacy Provider tab is available as required per business requirements.  To include the segment on the claim submission, click on the YES radial option. TAB – DUR/PPS The DUR/PPS tab allows you to submit one or more DUR/PPS entries.  Up to 9 entries are supported.  To include the segment on the claim submission, click on the YES radial option.   TAB – Compound The Compound tab enables you to submit full compound claims. Future development Segments The following segments will be developed in the future: Additional Documentation Facility Segment Narrative Segment Quick Entry Screen A quick entry screen for common data claims entry. USF Form