Claim Cycle

The billing cycle starts when a patient bill or claim is created by the system. The claims are billed sequentially. Sequential claim production will produce all formatted claims for the primary third party and all other claims will be in pended status.

The first step in the cycle process is to format a claim/patient bill. The formatting of a claim/patient bill involves gathering patient, guarantor and account information as well as identifying appropriate charges to be included on a claim/patient bill. The result of the formatting process is a form, which is the print image of the claim or patient bill to be produced. As part of the bill cycle process, each claim is given a priority within a third party, regardless of the third party priority on the account.

The facility can also define missing elements required to be completed before a claim is produced. If the element is not present, the claim will be held until the element is deemed no longer missing.

When all required billing criteria has been met, the claim/patient bill will continue in its cycle and be filed. The timing of when a claim/patient bill is filed is facility defined. Filing can be done electronically or a hardcopy printed. In addition, to assist the facility in going paperless, an archive file of all claims/patient bill transmitted or printed for the day is maintained and the claim is available on-line for viewing.

When the primary claim has been resolved (completed, canceled, denied), the secondary claims are reformatted and processed through the normal claim cycle.

When the claim is generated and is not in pended status, it is tracked. A filed claim will be tracked for payment.

Billing Cycle Process

PiMS gives you the ability to define your own billing cycle criteria for the different bill events, by third party and patient categories, patient type, financial class and special handling.

Interim billing is based on balance thresholds, number of days, month end or fiscal year-end. Final billing is based on number of days from the close of the account. Late charge billing and small balance write-offs are based on a combination of balance thresholds and number of days from last bill.

PiMS also gives you the ability to automate billing and claims decisions. When a claim reaches different points in the claim cycle, the claim can be automatically pended (waiting for the primary claim to complete), filed, released, or worklisted. When late charges are billed, a claim can be automatically reformatted, rebilled, or a supplemental bill generated. When a partial payment is received, a claim can be worklisted for review, or automatically completed and the balance either written-off or transferred to the next claim or guarantor. These decisions are also specified by insurance and patient categories giving you complete control over the billing process.

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.