Submitted Claims Guide

Theralytics gives the option to review submitted claims electronically (EDI) or non electronically (NON EDI). Please follow the instructions below to learn how this feature works.

What is the Submitted Claims Tab used for?

1. The Submitted claims area will show a list of the claims that have been submitted electronically or non electronically (NON EDI) to the clearinghouse or that have been marked as submitted internally.

   From the submitted claims area, you also have the option of resubmitting claims with a correction code, and submitting claims to a secondary payer.

How are claims moved into the Submitted tab?

1. Once an appointment is rendered, it moves into the Ready to Bill queue.
   1. If the payer does not accept electronic payment, then you can use the Submit Claim for Non EDI Payers option (confirm that the EDI Payer option for this payer is unchecked).
      
      
      
   2. You can also use the "Submit Claim for Non EDI Payers" button to move claims from Ready to Bill to Submitted if you have submitted these claims outside of Theralytics. This will work for EDI payers as well, simply use the Batch Form 1500 Generation button and choose the Mark as Submitted Option You may need to do this if you are looking to enter a payment for a claim that has not been submitted through Theralytics.
   3. What Not to Do When Submitting Claims - Only use the Batch EDI Generation button when you are ready to submit claims, as there is no way to “undo” a submission once started. 

How do I edit claims that have been submitted?

1. Changes that can be made directly from the Submitted Claims tab, but are not recommended until the payer has processed the claim (s). Click the blue edit icon underneath the Action column to bring up the Edit Service Code menu. You have the option to change:

   1. The number of units billed

   2. The rate per unit billed.

   3. Adding or removing modifiers.

   4. Adding or removing diagnosis codes.

   5. The practitioner

   6. The rendering provider for billing.

2. Please be aware that making any change from within the Submitted Claims area will not update the corresponding appointment. There will be a discrepancy between what was billed and what is shown on your schedule. Consult support for additional guidance. For any other changes (or to edit an appointment before resubmitting) you will first need to move the claim back to Ready to Bill to modify as needed.
    

3. For users looking to edit the time of a claim, the time can be modified on the schedule if the user has the "Modify Time after Rendered Permission enabled.

When (and when not) to move claims back to Ready to Bill

1. Any major change that needs to be made to the appointment (changes other than adjusting the units billed) will require moving the claim back to Ready to Bill, as submitted appointments cannot be edited. For example, but not limited to, changing insurance, changing service code, changing location, etc.
2. Please be aware that moving a claim back to Ready to Bill will delete all Office Ally and Payer response information attached to the claim. If you have submitted a claim and have received a denial from the payer you may not want to move the claim back to Ready to Bill unless the claim is being resubmitted as a brand new claim.

How do I resubmit claims that have been submitted?

The submitted claims tab allows you to resubmit claims with a resubmission code (Box 22) and submit to secondary insurance.

1. The Batch EDI Generation button within the Submitted Claims tab will display a set of resubmission codes once selected.                                                                 
2. Selecting Corrected, Void/Canceled, or Replace will require a control reference number to resubmit the claim. If you are enrolled in ERAs with your payers, the number will automatically populate. If you are not enrolled in ERAs you will need to review your EOB and add in the control reference number which may be listed as the payer control number. 
   1. 1 OR (Original Claim) clearinghouse rejection or submitting to a secondary payer for the first time. Certain payers may state you can resubmit a denial as OR such as Careleon. Please make sure to confirm with the payer first.

   2. 6 CR (Corrected Claim) applied based on payer recommendation. Please make sure to confirm with the payer first.

   3. 8 VR (Void Claim) used in the event of:

      • You need to refund the payment of a claim

      • If you have submitted to the incorrect payer and that payer has paid the claim

   4. 7 RR (Replacement Claim) - resubmission to the payer after correcting the claim internally.
      
      

3. Users should check approved resubmission codes with the payer prior to resubmitting claims. Some payers do not accept any replacement or corrected claims and require resubmissions to be sent as an original claim.           

4. The Batch EDI Generation for Secondary Payer button can be used if your client has a secondary payer. Before submitting claims to secondary, please make sure:

   1.  Secondary payer information has been added on the clients profile.

   2. Primary payer response has been entered either manually through Apply Payments or having the system download the ERA from Office Ally.

   3. Click Here for more information on secondary billing.

When will I need to manually adjust modifiers and service codes?

1. Adding in Modifiers and Alternate codes (for secondary claims only)
   1. When adding modifiers, use the modifier fields to the right of the service code to enter any additional modifiers that you would like applied to a claim.
   2. If you are submitting to a secondary that uses different codes (for example, H2019 vs 97153 for Direct Service), you may need to enter an Alternate service code to submit. Use the Alternate service code text area to enter the code.

Please be aware that changes made to the codes or modifiers will not be reflected on the schedule for these claims.