Enter a historical claim

Use the Historical Claim Entry for claim data which has been previously processed but isn't reflected in the history, for example a manually paid claim, a claim processed by another system, a balance remaining on a disputed case, or a negative claim used to adjust an incorrect historical claim.

This process won't generate a check or Explanation Of Benefits (EOB EOBs are sent to members and payees to inform them of the disposition of claims. Typically an EOB identifies the date and type of service, the billed amount, deductibles, co-insurance, and an explanation of any ineligible charges. An EOB can also be a helpful tool in identifying fraudulent claims, as the member receives notification even when payment is made to the provider. An EOB isn't a bill.). No payments are made, but the accumulators and the claim detail will update.

You can't manually pend or delete historical claims, and they complete to HI—Historical status.

From the Administration Processes menu, select the Claims Entry: Historical area and then double-click the Historical Claims Entry option depending on the type of claim (Professional, Institutional, or Dental).

Header workspace field descriptions

* indicates a required field

Field	Claim Type	Description
Type *	All	Claim type. This is a read-only field. Change the claim type `DENT` `INST` `PROF`
Received Dt *	All	Received date. The date the office received the claim. Enter or update the date in MM/DD/YYYY format (e.g. 01/05/2018 or 01052018). You can use the following date separators: (., -, /) or don't enter any separators. If your system is configured to tab over the date, it defaults to the current date. Important: If you resolved a claim's pends or copied a duplicate claim's data, the Received Date might not be the original received date. Depending on your software version, you might see a next to the Received Date field. Hover over this icon to view the claim's original received date.
Pay To *	All	Indicates who the payment will be made to: `Member`. `Provider`.
Patient Acct #	All	Patient account number.
Pre-Auth#	All	Pre-authorization number.
Member *	All	Member ID number.
Patient *	All	Patient associated with the claim.
Member Address	All	Address of the member associated with the claim.
Bill Type	Institutional only	Bill type is a 4-digit code that applies to institutional claims, where each digit identifies specific information: 1st digit is a leading zero and isn't used in ServiceXG. 2nd digit is the facility type. 3rd is the bill classification. 4th is the submission frequency.
Billing Provider	All	The tax ID number for the billing provider or organization that issued the bill for the services listed on the claim. Hint: Enter a character or two in a provider box and then click to display a look-up window where you can search for the provider.
Service Provider	All	The ID number for the provider who renders the services submitted by the billing provider. Hint: Enter a character or two in a provider box and then click the icon to display a look-up window where you can search for the provider.
Billing Name	All	The individual or organization that issued the bill for the services listed on the claim.
Provider Address	All	The address for the billing provider or organization that issued the bill for the services listed on the claim.
Service Address	All	The address of the performed services listed on the claim.
Admission Date	Institutional only	Date the patient was admitted. Enter or update the date in MM/DD/YYYY format (e.g. 01/05/2018 or 01052018). You can use the following date separators: (., -, /) or don't enter any separators.
Rel. Condition	Dental and Professional only	Related Condition. Condition(s) related to the claim, such as Accident, Illness, or Work Related.
I/A Date	Dental and Professional only	Date the illness or accident occurred.
Ref Physician	Professional only	ID number of the referring physician.
Place of Treatment (PoS)	Dental only	Place Of Service. Numeric code describing the location where service was rendered. The codes are defined by the plan administrators but also include basys defaults.

In the Header subtab, enter the Received Dt or tab through if your system is set up to automatically enter the current date.
1. In Pay To, choose Member or Provider as applicable.
  - Your system might default to Provider, if this is correct, tab through the field.
2. Enter the Member ID in the Member box. When you tab through the field, the Member Address updates.
  - If you want to enter the same Member for the previous claim, press Enter to update the Member and Address fields.
3. Select the correct patient from the Patient list.
  - Patient Notes might display together with a Patient Notes tab at the top of the screen depending on your system configuration.
  - Enter the billing provider's tax ID in the Billing Provider box.
    Hint: To search for the Billing Provider tax ID enter the ID or partial ID and then click.
  - Depending on your system configuration, as you tab through the fields, if there's only one billing provider, the Billing Provider name updates with the ID you entered.
4. Depending on your system settings, the Action Date and Issued Date:
  - are typically set with a date that is years in the past so the claims aren't included in any back end processing.
  - the default date is automatically entered when you tab into the date fields or press Enter.
5. As necessary complete the remaining fields. See the Claims Header workspace field descriptions above.
Click the Lines subtab.
1. In the diagnosis code International Classification of Diseases. A coding system developed by the World Health Organization (WHO) for the classification of diseases, symptoms, abnormal findings, external causes of injury, and cause of death. Includes both ICD-9 and ICD-10 codes. in the A box, enter codes if necessary to the right of the appropriate diagnosis pointer boxes.
2. Complete the Proc, Qty, Billed Amt, and BCode information.
  - If you don't enter a BCode, Procedure (code), or Billed Amt., you'll receive an edit.
  - To add a new claim line: When you tab out of the BCode field, the cursor focuses on to the right of the BCode. Click the icon to add a new line.
    Note: You can't insert a new line on EDI claims.
3. As necessary, complete the remaining fields on the Line workspace. See the Claims Lines workspace field descriptions in Claim Entry.

Access the Overrides workspace if you need to enter Override information.

Overrides workspace field descriptions

* indicates a required field

Field	Description
Claim Overrides
Stop Loss Payment	If a benefit payment is too large, it might qualify as a Stop Loss Payment, where the fund office only needs to cover up to a certain amount to avoid using up the fund reserves on one claim. Select `Yes` or `No`. The default is `No`.
Send LBC Transaction	The Labor BlueCard process enables self-administered benefit funds to access the BlueCross BlueShield (BCBS) provider network to process claims If you use the LBC process, but want don't want to send a transaction file to Blue Cross Blue Shield (BCBS) Illinois for a claim, select `No`. If you don't use BCBS as a Trading Partner, the option is disabled.
Liability
Patient Liability	Amount the patient owes. Note: The amount is calculated automatically, but you can override it on the Claim Entry or Processing Overrides workspace.
Provider Liability	Amount that is the provider's responsibility. For example, a provider belongs to a network and bills $90 for a procedure. The network only allows $50. If the claim is paid at 100% (no patient responsibility), then the provider is liable for the remaining $40. Note: The amount is calculated automatically, but you can override it on the Claim Entry or Processing Overrides workspace.
PPO Discount	The Preferred Provider Organization (PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount.) discount is the amount the member saves using a network provider. The PPO discount is the difference between the provider's billed amount and the PPO's allowed amount. If the plan doesn't use a PPO network, it will be zero. Note: The amount is calculated automatically, but you can override it on the Claim Entry or Processing Overrides workspace.
FSA Liability	Amount that could be FSA Accounts offered and administered by employers that provide a way for employees to set aside, out of their paycheck, pretax dollars to pay for the employee’s share of insurance premiums or medical expenses not covered by the employer’s health plan. eligible. Patient Liability—Non-reimbursable Ineligible Amounts. Note: The amount is calculated automatically, but you can override it on the Claim Entry or Processing Overrides workspace.
Overridden By	The operator ID of the person who last entered an override code/amount and the time.
Eligibility
Subgroup *	Code and name of the active subgroup A way to categorize group members into a certain set for benefit plans (e.g. active and retired employees). Subgroup distinctions are only used in Claims, COBRA and Eligibility. that is associated with a current health plan. Only active subgroups display in the list. If there's no active eligibility for a patient, the Eligibility override fields default (Subgroup, Plan, Coverage) to the patient's last active eligibility.
Plan *	Code and name of the benefit plan A benefit plan identifies the benefits an individual receives as the result of his or her association with a subgroup. associated with the selected subgroup. If there's no active eligibility for a patient the Eligibility override fields default (Subgroup, Plan, Coverage) to the patient's last active eligibility.
Coverage *	The coverage code identifies who is covered by a benefit plan type, for example, individual or family. Choices are limited to coverage options that apply to the selected benefit plan and the patient's relationship to the member.
Pay	Option that allows you to pay an ineligible claim if you have the appropriate permissions.
Ineligible	Option that allows you to designate a paid claim as ineligible.
Overridden By	The operator ID of the person who last entered an eligibility override code/amount and the time.
PPO
PPO	Preferred Provider Organization (PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount.). Code and PPO name. Choices are limited to PPOs for the selected benefit Plan and claim dates. If there's more than one line in the claim, once you choose the PPO, an Override PPO window displays: Click `Yes` to apply the override to all the claim's lines, or click `No` to only apply to the selected line.
Overridden By	The operator ID of the person who last entered a PPO override code/amount and the time.
Procedure (applies to Institutional claims)
Procedure	If both Revenue and HCPCS codes are present on a claim line, the override feature becomes enabled so you can choose which codes determine the claim eligibility and pricing. Revenue Code Revenue codes are three-digit codes that affect reimbursement and represent the healthcare services provided for a payer. HCPCS HCFA Common Procedure Coding System (HCPCS) Procedure Code for institutional (hospital) claims.
Overridden By	The operator ID of the person who last entered a Procedure override code/amount and the time.

If there's no active line item patient eligibility, the Eligibility override defaults to the last active eligibility associated with the patient and the Overridden By is cleared. The Lines workspace—Ineligible Code section updates with the IEB code and full billed amount.

Use the F7 key or click Verify.

Click the Links workspace if you need to enter Links information. See the Claims Links workspace field descriptions, Linked admissions messages, and Linked illnesses messages.
Click the Calc Detail workspace if you need to enter Calc Detail information. See Add, update, and delete claims calculations and Calc Detail workspace field descriptions.
Depending on your system settings, messages might display. Click the Messages workspace if you need to enter message information. See Add, update, or delete claims messages.
When you have finished entering the required claim information, click to validate and calculate the claim.

Important! You can't save historical claims with Edits on them. You must resolve all Pends and Audits (if any) before you can save the claim.
- See Save a claim for more information about messages and other behaviors that might happen when you save (depending on your system configuration).
- The claim saves with an HI status and you can't delete it.
- No checks generate from historical claims.