Using the Claim Entry/Edit Function

You can enter either a Professional, Institutional or Dental claim. Claim entry requires more transaction code sets and you can access and edit them from those menus as well as setup the component.

The following topics describe settings for the Claim Entry/Edit function:


Follow the instructions below to edit or entry claims.

1. Select Claim Entry/Edit arrow Professional / Institutional / Dental Claim in the main menu.

The "Claim Entry/Edit" menu
2. A screen like the one pictured below will be displayed. The following screen-shots will use the "Professional Claim" window. 

The "Professional Claim" window
3. Each segment or loop has its own set of editing screens listed on the left; they can optionally have different colors. The five (5) main data groups are:
Claim Information
Service Lines

Click one of these menu items to open to the relevant screen.

The left menu in the "Professional Claim" window

4. Once you have accessed a main category screen, you will see the top menu to access the individual screen. Use it to navigate along the claim.

Below you can see the billing provider information from a claim that was loaded from the database. To see and edit other provider types use the tabs at the top of the screen. The following image shows all the provider types that are part of the Professional Claim implementation.

The "Providers" tab selected in the "Professional Claim" window

Different sections may have a different range of tabs across the top. The following screen-shot shows top menu items for the "Service Lines" section selected in the left. This top menu differs from the top menu displayed on the previous screen-shot with the "Providers" section selected.

The "Service Lines" tab is selected in the "Professional Claim" window
5. To preview your changes, click "View Claim." A claim form will be shown on the screen.

The "View Claim" button
6. To save the changes, click "Save Claim."

The "Save Claim" button

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Defining Claim Entry Settings

1. To configure the claim entry options, select Claim Entry/Edit arrow Claim Entry Settings in the main menu.

The "Claim Entry Settings" menu

Alternatively, you can access the setup window from the Claim entry/edit window. Click the "Show Setup Screen" button. Read more in Using the Claim Entry/Edit Function.

The "Show Setup Screen" button on the "Professional Claim" window
2. The following screen will appear.

The HIPAA "Claim Entry Setup" window
3. The claim entry setup screen is divided into the following groups:
Colors for Tabs
Auto-Complete Mode
New Claims
Save Claims
Save Entities

Read the detailed descriptions further.

4. Once you have finished editing the options, click the Save button to save any changes or click the Close button do discard them.


Colors for Tabs

Unlike other screens in the HIPAA Claim Master, the window for claim entry has a lot of colors (see Using the Claim Entry/Edit Function). We decided to do this to give a clear distinction between the different groups of information. There are so many screens in this application that it is easily confusing to the data entry person. To develop a sense of intuition of where one is in the process and flow of the program we decided to add colors. You  also have the choice to not use colors for the tabs:

Do not use colors for tabs
Use colors for tabs

You are free to customize the colors. Click the button with the three dots to the right of each color to display the color selection screen where you can choose the color for a particular segment.

The color palette selection button

The color selection window


New Claims

HIPAA Claim Entry lets you predefine the version of the claim that you enter. This choice will influence the screens that you are presented with. Claims you create will be written to the database according to the implementation guide for the version that you choose.

Claim version options

Version in New Claims

Set new claims to the X12 4010 or 5010 standards. A claim loaded into the claim editor will preserve the standard it was saved in originally.

Use 4010
Use 5010

Information in New Claims

Set new claims to use Production or Test data.



Save Claims

Before saving a claim to the database, it can be validated against the X12 standard. The compliance engine will warn users of errors that would make the claim fail compliance, such as missing segments, incorrect datatypes, unrecognized qualifiers or excessive characters in a particular field.

Claim compliance validation options

Validate claims before save - runs the compliance engine to check for potential errors in a claim file
Don't save claim if warnings - if a claim fails the compliance check, it is not saved to the database


Save Entities

Saving entities to the database is an option for facilitating data entry. Providers, patients and payers are saved into a database after being entered for later retrieval. Entering a last name or ID will automatically fill the entity's remaining fields in the claim editor. They can be individually selected. To view currently saved entities, see entity editing.

Save entity to DB options

Checking an entity will allow a user to autofill a provider, payer, patient or subscriber in the claim editor by filling in the entity's ID.


Auto-Complete Mode

Entities saved to the database can be loaded into a provider, payer or patient form by typing out the relevant entity's name or ID. The ID and Name textboxes will suggest an entity to enter into the form and accepting will autocomplete the remaining details. To disable this capability for the ID or Name, check the appropriate box. To learn more about autocomplete for providers, payers and subscribers, see Provider, Patient and Payer Autocomplete.

Autocomplete options

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Provider, Patient and Payer Tables

Provider, Patient and Payer Tables

Filling in provider, patient, and payer details multiple times is a repetitive task that can be alleviated by storing the relevant entity in a table for later retrieval. For example, entering a provider's ID number will suggest a stored provider to select from and automatically fill the remaining fields in the provider form with the relevant data. To create the provider, patient or payer tables follow these steps:


1. Click Claim Entry/Edit arrow Create Tables for Entities

Create tables for entities menu
2. This opens the Create SQL Tables window. Here you can create the StoredPatient, StoredProvider, and StoredPayer tables. Check the appropriate database is selected and click Execute Script to create a table. If the table has been changed in a new release, clicking Compare Script with existing table will create a script to adjust the table. Changes to database tables do not occur often.

Create SQL Tables window
3. Click Execute Script. A new table will be created.
Table creation success

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Stored Patients

Stored patients can be viewed and edited in this screen. To open the Stored Patients editor, click Claim Entry/Edit and then Stored Patients:

Stored patients menu option

A new window containing all patients, both subscribers and dependents, will be opened. To create the StoredPatient table, see Provider, Patient and Payer Tables.

Stored Patient editing screen

The table contains all patients present in the StoredPatient table. Selecting a patient in the table will fill out the Patient Information form. Editing the fields and clicking Save Patient into Database will modify the contents of the selected patient's row to match your changes.

To create a new patient, click the New Patient button below the Stored Patients table, fill in the Patient Information, and click the Save Patient into Database button to save the new patient.

To delete an existing patient, select the patient in the Stored Patients table and click the Delete Patient button.

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Stored Payers

Stored payers can be viewed and edited in this screen. To open the Stored Payers editor, click Claim Entry/Edit and then Stored Payers:

Stored payers menu option


A new window containing all payers stored in the StoredPayer table will be opened. To create the StoredPayer table, see Provider, Patient and Payer Tables.

Stored Payer editing screen

The table contains all payers present in the StoredPayer table. Selecting one will fill out the Payer Information form beneath it. Editing the payer fields and clicking Save Payer into Database will modify the contents of the selected payer's row to match your changes.

To create a new payer, click the New Payer button below the Stored Payers table, fill in the Payer Information, and click the Save Payer into Database button to save the new Payer.

To delete an existing payer, select the payer in the Stored Payers table and click the Delete Payer button.

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Stored Providers

Providers stored in the database  can be viewed and edited in the Stored Providers editing screen. To open the Providers editor, click Claim Entry/Edit and then Stored Providers:

Stored providers menu option

A new window containing all payers stored in the StoredProvider table will be opened. To create the StoredProvider table, see Provider, Patient and Payer Tables.

Stored Provider editing screen

The table contains all providers present in the StoredProvider table. Selecting one will fill out the Provider Information form to the right of the window. Editing these fields and later clicking Save Provider into Database will modify the contents of the selected provider's row to match your changes.

To create a new provider, click the New Provider button below the Stored Provider table, fill in the Provider Information, and click the Save Provider into Database button to save the new provider.

To delete an existing provider, select the provider in the Stored Providers table and click the Delete Provider button.

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Creating CodeSet Tables

Some codesets are so numerous that it does not make sense to store them in an XML file. There are more than 25,000 procedure and revenue codes and more than 15,000 diagnosis codes in ICD-9 alone. For that reason we decided to store Procedure Codes, Diagnosis Codes, Revenue Codes and ZIP codes in the database. In the following example a Diagnosis Code table will be created.

Note: You need to configure the connection to the database first. See Setting up Database Connection.

1. Select DataBase arrow Code Look-up Tables in the main menu.

The Code Look-up Tables menu option from the main menu bar

 Alternately, a specific codeset's editor can be opened by clicking the appropriate Procedure, Diagnostic or Revenue Code option from either the Code Sets menu or the Claim Entry/Edit arrow Claim Entry/Edit CodeSets menu option.

2. The Code Set edit screen will appear.

The "Diagnosis Code" window
3. Initially the table does not exist in your database. To create the table, click the "Create table DIAGNOSIS" button.

The "Create table DIAGNOSIS" button
4. A table creation window will be displayed. 

The "Create DIAGNOSIS Table" window
5. Select the appropriate database and click the Execute script" button and the table will be created. 

The "Create DIAGNOSIS Table" with the "Execute" button highlighted
6. You will receive a success message like this. Click OK.

The success popup
7. Once the table has been created, you are redirected back to the "Diagnosis Codes" window. It looks different now and indicates that the newly created table exists.

The "Diagnosis Codes" window with the empty table

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Filling CodeSet Tables

Loading a Codeset Table can be done using a .xlsx spreadsheet, comma separated value (csv) textfile, or space delimited textfile. The following examples assume you have already opened a codeset's edit screen and will use the Diagnostic Codes codeset as an example.

The Diagnosis Codes codeset editing window.

 Tip: The diagnosis codes according to the International classification of Diseases (ICD) in the 9th revision are published by Ingenix or the AMA for example. You can also download them from the CDC-National Center for Health Statistics.

Loading from XLSX

1. Click the Load from XLSX file button.
The "Load ICD-9 Codes" button
2. Select an XLSX file to use by writing its full filepath or clicking the file selection button.

File selection button
3. Select a code type if applicable.

Code type selection for diagnosis codes.
4. Click the Load Codes button.


Loading from Text File

There are two ways to determine column position from a text file in order to build a table: with a delimiter such as a comma or semicolon in a character delimited file or knowing the each column's position in a fixed width file.

1. Click the Load from TXT file button.
Click the "Load ICD9 Codes" button.
2. Select a filetype to load the codesets from. Select File with positions if the codeset text file you wish to save to the database is a fixed width file or File with delimiters if the codeset file is character-delimited.
Text file type selection.
a. File with positions / fixed width - Select fixed width file that you downloaded or have available on CD/DVD. 

The layout of the text file is usually the code in position 1 through 12, and the description in position 13 through 44. If the first line contains headers, you can step over the headers by checking the box labeled First line in file contains headers.

Clicking Try One Line will open a message box with a single example row from the text file.
Click Load Codes to fill the database table.
b. File with delimiters / character delimited - Select fixed width file that you downloaded or have available on CD/DVD.

The delimited text file is usually delimited by a comma. The layout usually contains the codes in field 1 and full description in field 3. If the text file includes the column headers, check the box labeled First line in file contains headers.

Clicking the Try One Line button will open a message box with a single row from the text file as an example.
Click the Load Codes button to fill the database table.

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Viewing and Editing CodeSets

To view/edit code sets in HIPAA Claim Master, follow the instructions below.

1. Go to Entry/Edit arrow Claim Entry/Edit CodeSets in the main menu.

The additional code sets that are required for Claim Entry/Edit

Alternatively, you can access the codesets setup from the Claim entry/edit window. Click the Codesets button. Read more in Using the Claim Entry/Edit Function.

The "Codesets" button on the "Professional Claim" window
2. The Code Sets - From the sub-menu, select a code set name. The following menu items are available via the "Code Sets" menu:
Adjustment Reason Codes
Admission Type Codes
Admission Source Codes
Amount Qualifier Code
Condition Codes
Diagnosis Codes — See Creating Codeset Tables
DTP Codes
Facility Types
Filing Indicator Codes
Info Release Codes
Occurrence Codes
Occurrence Span Codes
Patient Status Codes
Place of Service Codes
Procedure Codes - See Creating Codeset Tables
Provider Taxonomy Codes
REF Codes
Remark Codes
Relationship Codes
Report Type Codes
Revenue Codes - See Creating Codeset Tables
Tooth Numbering Codes
Treatment Codes
ZIP Codes - See Creating Codeset Tables

Diagnosis, Procedure, Revenue and ZIP code sets are too large to store in memory. They can be edited like any other codeset but the database tables to store them are created separately.

3. To select, for example, the "Remark Codes" codeset for display, click the Claim Entry / Edit menu item and from the Claim Entry/Edit CodeSets dropdown menu options select Remark Codes:

The "Claim Entry/Edit CodeSets"
4. The Code Set configuration window for the selected codeset, in this case Remark Codes, will displayed. You can add additional codes by typing it into the blank row at the end of the list or edit the existing ones by double-clicking the field to edit it and type in the new value. Click the Save button to save the changes.

The "Remark Codes" code set configuration window

   As mentioned above, the procedure, diagnosis, revenue and ZIP codes are saved to a database. These four codesets have a slightly different codeset editing screen (shown below) but they behave in the same way. Since these codesets can grow very large, search boxes are provided to filter through codes or descriptions.

The slightly different "Procedure Codes" code set configuration window.

The codeset windows provide the following information:

Number of records in codeset — The total number of codes stored in the database.
Codes and their corresponding descriptions. A short description, standards version (ICD), city and state (ZIP) may also be included, depending on the loaded code table. The codes are indicated in the source EDI files. The descriptions are displayed instead of codes in the result easy-to-read files. For example, for Remark Codes there are the following codes and corresponding descriptions:
M1 - X-ray not taken within the past 12 months or near enough to the start of treatment.
M2 - Not paid separately when the patient is an inpatient.
M3 - Equipment is the same or similar to equipment already being used.

4. Click on the "Save" button to save the changes. Changes to the procedure, diagnosis, revenue and ZIP codes are saved automatically to the database.

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