Insurance Claim Workflow

The insurance claim process tracks reimbursement requests from your facility to insurance companies.

Claim Creation

Claims can be created:

• From invoices — After services are rendered and invoiced
• From coverage records — Based on pre-calculated coverage

Claim Details

Field	Description
Patient	The insured patient
Insurance Payor	The insurance company
Policy Number	Patient's policy reference
Claim Amount	Total amount being claimed
Coverage Details	Breakdown of covered services
Supporting Documents	Clinical documents, invoices, prescriptions

Claim Status Workflow

+----------+      +----------+      +----------+      +----------+
|  Draft   | ---> |Submitted | ---> | Approved | ---> | Settled  |
|          |      |          |      |          |      |          |
+----------+      +----------+      +----------+      +----------+
                        |                 |
                        v                 v
                  +----------+      +----------+
                  | Rejected |      | Partially|
                  +----------+      | Approved |
                                    +----------+

Status	Description
Draft	Claim being prepared
Submitted	Claim sent to insurance payor
Approved	Payor has approved the full claim
Partially Approved	Payor approved part of the claim
Rejected	Claim was denied (with reason)
Settled	Payment received from the payor

Claim Status Update

Track the progress of submitted claims:

1. Update the claim status as responses are received from the payor
2. Record approval/rejection reasons
3. For partial approvals, document which items were approved and which were denied
4. Track appeal submissions for rejected claims

Payor Payment Handling

When the insurance company settles a claim:

1. Record the payment received via Payment Entry
2. The system links the payment to the corresponding insurance claim
3. The claim status updates to Settled
4. The patient's invoice reflects the insurance payment
5. Any remaining balance becomes the patient's responsibility

Integration: Payment entries are automatically validated against insurance claims to ensure correct allocation of insurance payments.