We partner with Candid Health and Enter Health to handle full revenue cycle management process.

Prerequisites

In order to submit insurance claims, there are a couple of items you need to set up first.

Part 1: Create billing providers (EMR)

The billing provider is the provider or business entity submitting the claim and represents the person or entity being reimbursed. The billing provider should be the entity contracted with the payer.

Follow the instructions here to set up your billing providers.

Part 2: Create service facilities (EMR)

Next, set up your service facilities.

The service facility is location a medical service was rendered, such as the provider office of hospital. For telehealth, the service facility can be the provider’ location when the service was delivered (e.g. home) or the location where the in-person would have taken place. The service facility address listed must match what you provided to the payer during the credentialing process.

Follow the instructions here to set up your service facilities.

Part 3: Create referring providers (EMR)

Then, set up your referring providers.

The referring provider is the provider who directed the patient for care to the provider rendering the services being reported.

Follow the instructions here to set up your referring providers.

Part 4: Set patient demographic details (EMR or Patient Portal)

We pull the patient’s name, gender, MRN, date of birth, and address for the insurance claim from the patient’s profile. This information is automatically added to the patient profile during the registration process. F

ollow the instructions here to ensure that all the pertinent demographic details are set on the patient’s profile.

Part 5: Create patient insurance policies (EMR or Patient Portal)

Add insurance policies for each patient.

Follow the instructions here to set up each patient’s insurance policies.

Part 6: Set up RCM integration (EMR or Patient Portal)

Lastly, you need to set up an RCM integration with Candid Health or Enter Health.

Follow the instructions here to set up the RCM integration.

Steps:

Step 1: Create an insurance claim (EMR)

To create a insurance claim:

• Go to the EMR (e.g. emr.avonhealth.com)
• Click on the hamburger menu on the top left corner > Patients
• Click on the “View Chart” button of the appropriate patient
• There are two ways to create a new claim
  1. Click on “Add” button on the top right corner and select “Insurance Claim” in the dropdown
  2. Pick the “Bills” shortcut in the patient panel on the left side of the screen, click on “Add a new bill” button on the top right corner, and select “Insurance Claim” in the dropdown
• Fill out the requisite information
  • Name: Name of the claim
  • Patient: Verify that the patient name, gender, MRN, date of birth, and address are accurate.
  • Appointment: Appointment this claim is associated. If there is no appointment this claim is associated, leave this dropdown blank.
  • Visit Note: Visit note this claim is associated with. If there is no visit note this claim is associated with, leave this dropdown blank.
  • Primary insurance: Patient’s primary insurance policy. This field is auto-populated with whichever policy the patient has set as their primary insurance policy. If you want to change the patient’s primary insurance policy to a different policy for this bill, simply choose another policy from the dropdown.
  • Secondary insurance: Patient’s secondary insurance policy. This field is auto-populated with whichever policy the patient has set as their secondary insurance policy. If you want to change the patient’s secondary insurance policy to a different policy for this bill, simply choose another policy from the dropdown.
  • Rendering provider: Provider that provided the medical services. This field is auto-populated with either:
    • The provider who wrote the note that is generating this bill, if this bill was generated from a note
    • The provider who clicked “Create a new bill,” if this bill was NOT generated from a note If you want to change the rendering provider, simply choose another provider from the dropdown.
  • Referring provider: Provider who directed the patient for care to the provider rendering the services being reported.
  • Service facility: Location a medical service was rendered, such as the provider office of hospital. This field is auto-populated with the default service facility set in Prerequisites Part 2 of this document. If you want to change the service facility, simply choose another service facility from the dropdown.
  • Billing provider: Provider or business entity submitting the claim and representing the person or entity being reimbursed. This field is auto-populated with the default billing provider set in Prerequisites Part 1 of this document. If you want to change the billing provider, simply choose another billing provider from the dropdown.
  • Prior Authorization: Number indicating that the services provided on the claim have been authorized by the payer. If there is no prior authorization number, leave this box blank.
  • Permissions: Permissions that:
    • Patient has authorized release of medical information for billing purposes
    • Patient has authorized payments to be made to the billing provider
    • You have accepted patient's authorization for payments to be made to the billing provider
  • Diagnoses: Relevant diagnoses for this claim. If this bill has been generated from a note, the ICD codes from the note are automatically added as diagnoses. For each diagnosis, specify whether it is active, onset date, and end date (if not active anymore).
  • Billing Items: Relevant billing items for this claim. If this bill has been generated from a note, the CPT codes from the note are automatically added as billing items. For each billing item, specify the date of service, any modifiers, quantity of the procedure performed, fee per procedure, and associated diagnoses. Each billing item must have at least one associated diagnosis.
• All information set is autosaved so click “Finish and Go Back” if you are done with the claim for now

Step 2: Request review (EMR)

You can request review of the insurance claim before submitting it. Follow the instructions here to request review.

Step 3: Add comments (EMR)

You can add comments to the insurance claim before submitting it. Follow the instructions here to add comments.

Step 4: View, edit, and delete insurance claims (EMR)

To view, edit, or delete insurance claims:

• Go to the EMR (e.g. emr.avonhealth.com)
• Click on the hamburger menu on the top left corner > Patients
• Click on the “View Chart” button of the appropriate patient
• Either:
  • Scroll through the patient’s chart to find the desired insurance claim OR
  • Click the “Bills” shortcut on the patient panel and scroll to find the desired insurance claim
• If any of the claims have the a “Missing Information” or “Denied” status, log into your Candid Health portal to see what you need to fix in your claim before resubmitting
• Click on the insurance claim card to go into viewing mode
• Toggle the top dropdown to go into editing mode
• Scroll to the bottom right-hand corner of the card to find the “Delete” button (NOTE: the “Delete” button is only visible when you are in editing mode)