Transitioning Claims from ClinicTracker to BillingTracker

While the transition process is automated and happens quickly, a lot of processing goes on in the background that is helpful to understand.

 

What Happens Behind the Scenes When a Claim is Transitioned Automatically

Check That Insurer Plan Requirements are Met (e.g. DOB required)

Calculate the fee

Check appointment status

  1. If status is set to transition to BillingTracker.
  2. If a price override has been assigned at the time of appointment.
    • Set fee to the override price.
  3. If a specific Cancelation Fee has been entered for the status.
    • Set fee to cancelation charge associated with appointment status.
  4. See if patient is reduced-fee eligible.
    • If so, find the matching reduced fee schedule.
  5. Check the fee schedule table for a matching record.
    • If so, set fee to matching fee-schedule rules.
  6. If no match, refer to the default pricing information configured in the ClinicTracker Maintenance -> Service Input setup form.

Calculate the quantity

  • Check the ClinicTracker service setup screen to see if a service charge is based on duration.
  • If not, assign a quantity of one.
  • Otherwise, calculate quantity and round based on the rounding rule (e.g. round to the nearest quarter-unit, round up to the nearest half unit, etc.)
  • The actual fee will be multiplied by quantity to determine the charge.
  • Cancelation fees will always have a quantity of one unit.
  • Override fees will always have a quantity of one unit.

Create the claim record

  • Pull all appointment information over from ClinicTracker.
  • Pull all current insurance information over from the client’s insurance record in ClinicTracker.

Check for modifiers

  • Examine the service, primary payor, and clinician, and determine if any rules have been configured for automatically applying modifiers.
  • If no match is found, proceed to the next step.
  • If a match is found, insert the 1-4 associated modifiers.
  • If more than one match is found, choose the least generic rule. For example, a match on a specific service and insurer (with a clinician option of “All”) would be selected over a match on service (with payor and clinician options of “All”).

Determine copay based on regular/group service type.

Split the actual fee between the copay assigned to the patient and the remaining amount assigned to the primary payor selected for the appointment.

  • If the charge is less than the copay, assign the full amount to the client.
  • If the payor has a Claim Format of the Patient Statement, the full amount will be assigned to the client.
  • If the service is configured with Bill Patient Directly option, the full amount will be assigned to the client.
  • If the status is other than “Showed Up” a cancelation fee is charged.

 

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