Claim Form and Patient Bill Formatting

The formatting of the claim has been moved from the application program to online profiles to allow for maximum flexibility in meeting the evolving state, federal and private payer regulations. All claim forms and patient bills can be viewed online providing the biller with the exact format of a hard copy. Formatting of the claim is not limited to HCFA 1500 and UB92, but because of the online profiles, each payer’s regulation format can be constructed both for electronic claims and paper.

Claims

The billing process consists of three major components, the Billing Event, Patient Bill Generation, and Claim Generation. Billing events are used by PiMS to indicate when an account is considered billed, when individual charges are considered billed, and when patient bills and claims should be generated. Patient bills are defined as itemized lists of charges for the patient. Claims are defined as bills for the third party/insurer.

PiMS can generate claims for all the account’s third parties or selected third parties at the time of a billing event. The following are examples of various claim generation criteria for an account:

• As an example, claims for third party "ABCD" can be generated on Tuesdays if it is as least seven (7) days after discharge or the charges reaches $10,000.
• Month end cycle billing for recurring patients or monthly accounts.
• Separate claims generated on types of charges, i. e., DME and Ambulance.
• Rebill or supplemental bill for late charges.
• The ability to control bill/claim generation by day of the week, day of the month, fiscal year end.

Proration/Expected Reimbursement

The expected reimbursement for claims is calculated using information from the insurance plan gathered through insurance verification. The claim is prorated based on remaining coverage, percentage of coverage, remaining days, and any special out-of-pocket requirements. There are three tiers of benefits supported by PiMS proration, one being lifetime benefits.

When the claim is prorated, the remaining balances are transferred to any secondary claims. The secondary claims are pended, waiting for the primary to be paid. Once the primary has paid, any remaining balance is transferred to the secondary claims that are reformatted and released for processing.

If there are no secondary claims, the remaining balance is automatically transferred to the guarantor. PiMS ensures that the guarantor responsible amount and the third party balances equal the account billed balance by managing the balance transfer process.