In this article we'll discuss what the Claims Report is and the Claim Report Workflow; how to setup the report and use it as a reference when submitting insurance claims for completed Client Assessments.
Click any of the index links below to jump ahead!
Index:
What is the Claims Report?
In a nutshell. 🥜
The Claims Report was designed to be a tool for those who handle insurance billing at a Clinic.
The two main functions of the report are:
To act as a resource for your Clinic's billers to reference when submitting Assessment claims. With the Claims Report you can define which CPT codes, modifiers, and units are to be used when your clinic submits claims to insurance companies.
To keep track of the current submission status of insurance claims for all Assessments completed by Clients using Blueprint. This will help to ensure every eligible Assessment administered via Blueprint gets submitted to insurance.
Permissions
Who has access to the Claims Report?
❗️ Clinicians can access/edit the Claims Report only if they also have the Biller permission
✅ Billers can access/edit the Claims Report
❗️ Supervisors can access/edit the Claims Report only if they also have the Biller permission
❗️ Admins can access/edit the Claims Report only if they also have the Biller permission
The Workflow
The cycle of the Claims report -- from initial setup to everyday use. 🔄
💡 Click the image to open it in a new tab!
Let's dive into each of these steps!
1. Billing Setup
Laying the insurance billing foundation. 🛠
Billing Setup is the initial step in using the Claims report. It only has to be completed once, but can be updated at anytime.
During Billing Setup you will choose which attributes (insurance companies, CPT codes, modifiers and units) anyone at your clinic may want to use when submitting insurance claims.
To begin Billing Setup:
Click Reports from the Primary Navigation Bar and select Claims
Click Billing Rules in the upper-right
Click Billing Setup in the upper-right
Billing Setup is completed in 4 parts:
A. Selecting Payers (Insurance Companies)
B. Selecting CPT Codes
C. Defining Units
D. Selecting Modifiers
A. Payers (Insurance Companies)
In this step of Billing Setup you will choose all of the insurance companies your clinic may work with. This can be updated at any time.
💡If you have Clients who are self pay, select Self Pay from the list of payers in this step.
B. CPT Codes
CPT codes are the numerical codes used primarily to identify medical services and procedures furnished by qualified healthcare professional.
In this step of Billing Setup you will select which CPT codes you may use to submit insurance claims for Assessments administered via Blueprint.
Each CPT Code is different, and each insurance company has different parameters in which they reimburse for each code. Check with the insurance company for more information.
💡 If you need an insurance company that isn't in our current list -- let us know! We can add them in for you!
CPT Code | Definition / Use Case |
96127 | Brief emotional/behavioral Assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale, etc), with scoring and documentation, per standardized instrument. |
96136 | Psychological test administration/scoring by physician or other qualified healthcare professional, two or more tests, any method. |
96138 | Psychological test administration/scoring by technician or other non-qualified healthcare professional, two or more tests, any method. |
96146 | Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only.
💡 Another common CPT code used by Blueprint Users. |
C. Units
Units are reported based on the number of times the procedure is performed, as described in the HCPCS code definition (often once per day).
Some CPT codes include the number of units in the code itself. For example, based on the description of 96127, it is assumed that 1 Assessment was done. So if the Client completed more than 1 Assessment on that day and you bill with that code, then you will want to identify that in the Unit.
The definition of CPT code 96136 however specifies it is to be used for 2 or more Assessments, so if your Client completed 2 Assessments that day, then you would submit that claim with as 1 Unit of 96136.
If you're unsure which CPT code you should use when submitting, be sure to check you fee schedule directly.
D. Modifiers
A modifier is a two digit code that indicates the service rendered has been altered by some circumstance, but does not change the definition or the code.
In this step of Billing Setup you will select which modifiers you may use to submit insurance claims for Assessments administered via Blueprint.
Similar to CPT Codes, each modifier is different and each insurance company has different parameters/requirements in which they reimburse for. If you're unsure which modifiers you should use when submitting (if any), be sure to check with the insurance company directly.
Modifier | Official Definition / Use Case |
59 | Identifies procedures/services, other than E/M (non-evaluation and management) services, that are not normally reported together, but are appropriate under the circumstances. |
95 | Identifies synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. |
XE | Identifies a separate encounter; a service that is distinct because it occurred during a separate encounter. |
2. Billing Rules
Defining custom billing scenarios and guidelines. 📝
Some insurance companies have different coding requirements for claims based on
the Client's specific insurance company
how many Assessments the Client completed on that date of service
the license level of the provider who administered the Assessment
Using the attribute that were defined during Billing Setup, Billing Rules enable you to define exactly which CPT codes, modifiers, and units should be used when submitting a claim based on these three variables, making the Claims Report a fantastic tool to keep all billing scenarios and specifications in order.
To setup or edit Billing Rules:
Click Reports from the Primary Navigation Bar and select Claims
Click Billing Rules in the upper-right
The rules are grouped by license level, then again sorted by Insurance Company.
💡 Click the blue license level title bars to collapse/open the sections for easy viewing.
Rule | Options |
Submit Claim | This rule is asking Are you going to submit this claim to insurance?
This rule has two options:
|
CPT Code | This rule defines which CPT code should be used when a provider of a particular license level administers an Assessment for a Client based on their insurance company. |
Modifier | Defines which Modifier should be used when a provider of a particular license level administers an Assessment for a Client based on their insurance company.
The options are available here are based on the selections made during the initial Billing Setup. |
3 & 4. Referencing & Updating the Claims Report
How to use the Report. 🔍
When it's time to submit claims to insurance, you can reference the Claims Report to see which Assessments are ready to be billed and which codes to bill them with.
After an Assessment has been completed by a Client it will appear in the Claims report with a Claim Status of Won't submit or Ready to submit depending on your Billing Rules.
Claims that have already been submitted to insurance will have a Claim Status of Submitted.
When you're ready to submit claims, here's how you can use the Claims Report to help do so:
From the Primary Navigation Bar Click Reports then select Claims
You'll see all Assessments that have been completed in the current month. Scan the report for all Assessments with a Claim Status of Ready to submit
💡Sort the Claims Report by Claim Status by clicking the title of that column to easily group and see all Assessments that are ready for submission.Create and submit claims for those Assessments (using your EHR or other preferred way of billing) using the CPT Codes, Modifiers, and Units as you see defined on the report
Update the Claim Status to Submitted
That's it! 🎉 Access the report any time to repeat the process on your preferred billing schedule.
FAQ
Q: Will all Assessments populate in the Claims Report?
A: Yes, every Assessment will populate in the Claims Report immediately after it has been completed by a Client.
Q. Can I update the Claim Status once the claim has been paid by insurance?
A: No. Currently we only have the option to update the Claim Status with the status of submission. We hope to add additional statuses in the future!Q: What's the difference between Billing Setup and Billing Rules?
A: Billing Setup is the initial step in using the Claims report. Billing Setup enables you to choose which attributes (insurance companies, CPT codes, modifiers and units) your clinic may want to use when submitting insurance claims while leaving unnecessary or inapplicable attributes hidden.
Billing Rules is where you can define a variety of billing scenarios for your clinic's Providers based on their license level using the attributes you selected during Billing Setup. Billing Rules are important because insurance companies may have specific claim requirements based a number of variables, so creating rules for each scenario will make billing for Assessments a breeze... at least breezier. 😉Q. Where do I specify which insurance a Client has?
A: On the Client's profile > Client Info tab > Insurance
Q. What about my self-pay Clients?
A. Self-pay can be added in as an insurance option during Billing Setup and set as the insurance on the Client's profile.
You can then create a Billing Rule to address how self-pay billing scenarios should be submitted (or not submitted) to insurance.
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