Claims

Pre-authorise an insured patient's stay, claim the bill from the insurer or government scheme, and follow the claim to payment or rejection.

Claims follows money owed by insurers and government schemes. You ask for a pre-authorisation before or during the stay, raise a claim for the bill, and record the insurer's answer. Nothing posts until a claim is paid or rejected.

Before you begin

• The insurer or scheme exists with the kind Insurer or Government scheme. See Panels & Insurers.
• The bill was billed to the panel, at the counter or on the IPD final bill. See Bill a panel patient and send the claim.
• You need the HIMS billing create right to raise claims and record answers.

Where to find it

Open Hospital → Finance → Claims. The page is titled Insurance & Scheme Claims.

Request a pre-authorisation

1. Click the Pre-authorisations tab.
2. Click New pre-auth.
3. Choose the admitted patient, the Insurer / scheme, the Treatment and the Estimated cost.
4. Click Request.

When the insurer answers, click Approve (with the Approved amount), Reject, Cancel or Request again on the row.

Raise a claim

1. On the Claims tab, click New claim.
2. Pick the bill from the list. It shows bills charged to an insurer or scheme that have not been claimed yet.
3. Type the Insurer reference and Notes if you have them.
4. Click Submit claim.

The claim takes the bill's credit amount and a CLM- number. An approved pre-authorisation for the admission is attached by itself.

Follow a claim

Click a claim to open it, then choose what happened:

• Approve: type the Approved amount and click Save approval.
• Resubmit: write What was corrected or sent and click Mark resubmitted.
• Mark paid: type the Amount received, choose where it was Received into and click Record payment.
• Reject: give the Insurer's reason and click Reject and write off.

The stage boxes at the top (Submitted, Resubmitted, Approved, Paid, Rejected) show counts and amounts. Click one to filter the list.

What happens in the books

The bill already put the amount on the panel receivable (1615).

• Paid: the bank or cash account is debited with the amount received, any short-payment is debited to Panel disallowance (5910), and 1615 is credited with the whole claim.
• Rejected: 5910 is debited and 1615 is credited with the whole claim.

Common questions

The bill is not in the New claim list. It was not billed to an insurer or scheme, it is already claimed, it was put on a panel invoice, or it was voided.

The insurer paid less than claimed. Record what you received with Mark paid. The difference is written off as disallowed.

Can I claim a corporate panel's bills? No. Corporate and panel bills are invoiced monthly from Panels & Insurers.