Creating and Submitting Insurance Claims

Creating a new Insurance Claim from the Calendar

To create a new claim, go to a session in the Calendar and select a client. Then go to Payment Actions and Create Claim.

The Create Claim view will pre-populate information based on pre-entered details from Services & Fees, Client Session, Client Coverage etc. You can make changes to your claim in this view that only impact the individual claim itself.

Creating a Claim from the Clients View

You can also create new claims from the Clients view. This enables you to create more than one claim at once by selecting multiple services at the same time.

First, select Clients, then Insurance, and finally select the Claims tab.

Next, you can select multiple services at once by selecting the check boxes to the left of each entry. After you have made your selections, select Create Claim to continue to the Create Claim view.

Here you will see the same view that we explored when creating a claim from the Calendar view, however now there are multiple claims listed in the same view, which can be expanded by selecting the chevrons to the left.

Under the Prior Authorizations tab you can enter information pertaining to prior authorizations such as the Prior Authorization Number, the CPT Code, and the dates it is Valid From and Valid Until.

Create Claims View

Learn more about each section of the Create Claim view below:

Services

The Services drop down menu allows you to modify the service provided at the session.

Billing Provider

The Billing Provider can also be modified here so that you can easily swap between provider profiles, depending on your payer enrollment status and claim submission preferences.

Place of Service

You can change the Place of Service in case this impacts claims processing.

Units and Modifiers

You can also change the number of Units and Modifiers for a service here as well.

Diagnostic (DX) Code

Diagnoses (DX) Codes from the Client Profile will automatically populate here for your convenience.

Amount Charged and Paid

You can manually change the amount Charged on a session by session basis here. The amount already Paid can also be entered here.

Insurance Plan

You can select an insurance plan set up for the client here.

Other

The Other section includes information about whether or not a client is In-Network, the ICN Number, as well as information on whether or not the service was related to an Auto Accident.

When submitting a new claim, you must check the acknowledgement boxes at the bottom of the View Claim window.

Required Information for Claim Creation

Before you can successfully create and submit an electronic claim, certain fields must be completed or auto-populated by the system. If any required data is missing, incomplete, or invalid, the system will show the available action in a disabled state until you have completed the requirements.

Prerequisites for a 'Ready to Submit' claim

Before a claim can appear in the system (e.g., in Ready to Submit status), the following setup steps must be completed:

1. Billing Profile for Provider – A billing profile must be created and active for the therapist submitting the claim.
2. Payer Enrollment – The insurance payer must be added to the system and enrollment must be active.
3. Client Contact & Clinical Details – The client profile must include Phone Number, Full United States address, and Diagnosis code(s).
4. Insurance Coverage – At least one insurance coverage plan must be added to the client profile with the required policy holder details.
5. Attended Session – The client must have at least one attended session recorded.
6. Invoiced Session – The attended session must be invoiced to generate claimable charges.

The table below outlines all fields used in claim creation, whether they are required, how they are populated, and any important notes for completion.

Submitting your Claim

Once you have entered in all of the necessary information, the Submit Claim button will turn green and selecting it will submit your claim.