Claim Submission and Payment Process (US-only)

This article provides a detailed explanation of the claim submission and payment process through Zanda integration with APEX

Overview

Customers who have completed the APEX enrolment and have a valid Vendor ID gain access to additional features in the Sales > Insurance menu, including:

• Claims
• Claim Payments
• Eligibility

In this article:

• Steps to Submit a Claim
• Claim Statuses
• Viewing Claims
• Fetching Claim Status Updates
• Viewing Claim Payments
• Explanation of Benefits (EOB)
• Automatic Payment Allocation

Steps to Submit a Claim

1. Generating a Claim:

   • Open an invoice edit page via an appointment panel or a client profile.
   • Click 'Create Claim' button
     

1. • A claim in a 'Draft' status will be created, and a CMS - 1500 form. Check the claim details and fill in any additional required details. 
   • Click  'Submit Claim'.
     
     
     

2. Pre-Validation:

   • When submitting a claim, the Zanda system performs pre-validation checks to ensure all required data is filled.  The fields missing the required information will be highlighted red. Enter the information and try submitting the claim again.
     
     

3. Claim Submission:

   • If all data is valid, the claim is submitted to Apex.
   • If Apex identifies missing or incorrect data, the claim is marked as Failed. Additional errors will be displayed at the top of the claim form.

4. Resubmitting Failed Claims:

   • Correct the errors directly on the form.
   • Hit Submit Claim again. No need to create a new claim.

Claim Statuses

• Draft: Claim prepared from invoice ##
• Failed: Claim submitted and validations failed
• Denied: Claim submitted and validations failed
• Accepted: Claim passed validation
• Submitted: Claim submitted and is ready to be processed by the clearing house
• Paid: Claim approved and paid

Viewing Claims

• To view and manage your claims, navigate to the Sales > Insurance > Claims menu. Here, you can utilize the available filters to generate a list of claims that match your specified search criteria.

• The generated list of claims will include the following information:
  • Claim #
  • Date Created
  • Status
  • Date Updated
  • Client Name
  • Insurer
  • Practitioner
  • Amount
  • Invoice#
  • Note: claim note, if any made
  • Actions: the actions menu allows to make edits, delete or resubmit the claim and view its submissions history

• You can add or remove columns from the claims list by clicking the 'Choose Columns' button above the list and checking or unchecking the required columns: 

• To see the deleted claims, enable the 'Show Deleted' switch below the filter, before you run the search:
  

Fetching Claim Status Updates

• Manual Updates:
  Users can click the Fetch Status Updates button to retrieve updates for claims that are Submitted but not yet paid, denied, or rejected.
  
  

• Automatic Updates:
  Status updates are retrieved automatically every day at noon (Mountain Standard Time).

Viewing Claim Payments

• Navigate to the Sales > Insurance > Claim Payments section to view details of claims that have been paid.
• Payments can be filtered:
  • By Date Range
  • By Client
  • By Insurer
    
    

• Once you set the search criteria, click the 'Search' button to generate the payments list. 

• Use the Choose Columns option to add or remove table columns:

Explanation of Benefits (EOB)

• Each paid claim is associated with an EOB (Explanation of Benefits), which includes:

  • Payment details (e.g., check or EFT number)
  • A breakdown of claims covered under the payment
  • Total amount paid

• Multiple claims from the same client and payer can be grouped under one EOB. These payments are listed separately in the system for each claim.

Automatic Payment Allocation

• When a claim payment is received:
  • The payment is automatically applied to the associated invoice.
  • The invoice status will reflect a $0 balance, indicating it has been fully paid.
  • Manual allocation is not required.