Claim session

Depending on what you need to do and your role and permissions, there are three different ways to work in HealthClaims.

Claim information—find professional, institutional, or dental claims information for a member to resolve issues or answer questions.
Claims entry—enter a new professional, institutional, or dental claim.
Claims processing—edit professional, institutional, or dental pended claims.

The claim session provides access to claim and line item details, alerts, and payment information, depending on your permissions. Refer to the ServiceXG Claim session video for an overview of the Claim session, including how to navigate in a Claim session, set Claim session display preferences, and log interactions with members or dependents about a claim.

Tabs

Claim session tabs have a specific icon so you can easily identify Claim Sessions from other types of sessions.

When you open a claim in a claim session, the default claim session tab displays. You can set up the claim session default tab via the Personalize option on the Home session. To learn more about each claim session tab is designed, Claim information.

Navigation pane

The claim ID and the patient's name are at the top of the navigation pane.

The alert icon indicates there are notifications (alerts and comments) for this claim. If you point at the alert icon, you'll see the total number of alerts and comments for the claim. See Alerts for more information.

The menus you have access to show on the navigation pane.

Data tiles—the Claim Information data tile and four additional rotating data tiles are below the menus. The data tiles can provide answers to most of your member's claim inquiries, including the claim's status and payment details.

The five data tiles show claim summary, fund, patient, billing provider, and claim service provider information.

Navigation pane field descriptions

Field	Description
Patient ID	The patient's SSN followed by an asterisk () and the patient's dependent number. Hint:* If the dependent number is `0`, the patient is the member.
Relation	Indicates whether the patient is a member or a dependent.
Member Name	The member's full name.
Alternate ID	The member's primary alternate ID. Note: If the member has multiple alternate IDs, they're listed on the Member Information page under `Alternate ID`.
Status	The claim's status. See Claim statuses for more information.
Status Date	The date on which the claim's status was last updated.
Status Operator	The operator who last changed the claim status.
Entry Date	The date the claim was entered on.
Entry Operator	The operator who entered the claim.
Received Date	The date the office received the claim.
Claim Age	The age of the claim from when it was received until now (current date minus the received date). This will only display for claims the `HA`, `HP`, or `IP` status.
Billed	The total amount billed by the claim.
Ineligible	The claim amount the patient is ineligible for.
Prepaid	The total prepaid amount from all lines of the claim.
Prepaid Type	The prepaid type: `Medicare` `Other Insurance` `Member` `Multiple` (only displays if the `Prepaid` amount consists of more than one prepaid type)
Paid	The claim amount that has been paid for as of today.
Pay To	Who the claim is being paid to (member or provider).
Action Date	The date on which the claim was most recently updated.
COB	Indicates whether the member has any COB A provision for determining benefits when a member has more than one benefit plan. in the system.
Open Dispute	Indicates whether the claim is currently being disputed. If the claim has an open date with no closed date, `Y` (yes) will display.

Field	Description
Total Allowed	The claim's total `Allowed` amount.
Total Deductible	The claim's total `Deductible` amount. The sum of the claim's `Annual`, `Lifetime`, `Illness`, `Month`, and `Other` deductibles.
Total Copay	The total copay amount taken. The sum of the claim's `Copay` and `Day` copay columns.
Total Co-Ins Amt	The amount the patient owes when the claim will be paid at a percentage other than 100%. If each line of claim pays at 100% co-insurance rate, no amount will display in this field. Otherwise, the `Patient Liability` will display here along with any other amounts the patient owes.
Total COB Allow	The total of the claim's `Medicare Allowed` and/or `Other Allowed` fields.
Total COB Paid	The total of the claim's `Medicare Prepaid` and/or `Other Prepaid` fields.

Field	Description
Fund	The claim's associated fund.
Group	The patient's group.
Subgroup	The subgroup the claim's patient is eligible for.
Plan	The patient's contract plan.
PPO	The Preferred Provider Organization (PPO) associated with the patient's coverage.
Coverage	The patient's coverage type
Schedule	The patient's associated benefit schedule.

Field	Description
DOB	The patient's date of birth.
Age	The patient's current age.
Gender	The patient's gender.
[Address]	The patient's current active address.

Field	Description
ID	The billing provider's system ID.
Name	The billing provider name.
NPI	The billing provider's National Provider Identifier (NPI).
Billing Address	The billing provider's address.

Field	Description
ID	The service provider's system ID.
Name	The service provider name.
NPI	The service provider's National Provider Identifier (NPI).
Service Address	The service provider's address.

The claim summary data tile shows when you first open a claim session. However, if you change it and open a new Claim session, the new session will show the currently selected data tile.

Click each small circle to cycle through the data tiles. To set the default data tile, see Personalize your session.

If Elipses icon: point to display more information shows next to a value, point to it to show more information about that value. For example if there was a prior payment adjustment, point this icon will show next to the Paid field and when you point to it, the PPA A way to recover a previous overpayment by deducting the amount from a check issued to the same payee until the overpayment is recovered. This reduction has no impact on the benefit of a claim; the impact is on the amount of the check. amount and the amount issued by check.

Session pane

The Session pane at the bottom of the screen is where you can add correspondence items for the patient. If the patient is a dependent, you can choose to add correspondence for the dependent or member.

You can set up Claim session default correspondence settings via the Personalize option on the Home session.