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Claims Processor Overview

The Claims Processor is a powerful tool designed to simulate and calculate prospective payments for various Medicare payment systems. It allows users to input claim data, validate it against CMS rules, and receive detailed pricing results.

Key Features

  • Multi-Module Support: Process claims for IPPS, OPPS, IPF, IRF, and LTCH.
  • Real-time Validation: Receive immediate feedback on code validity and missing fields.
  • Integrated Data: Access built-in fee schedules, MUE edits, and provider data.
  • Test Claims: Load pre-configured test claims to explore different scenarios.
  • Import Capabilities: Import claims from JSON or EDI-X12 formats.

Interface Tour

The Claims Processor interface is divided into logical sections to streamline data entry.

1. Top Section: Patient & Provider Info

The top section captures essential patient demographics and provider information. - Patient Info: Name, ID, DOB, and gender. - Provider Info: Billing and servicing provider details, with integrated search. - Claim Details: Basic claim identifiers like TOB (Type of Bill) and dates.

2. Middle Section: Clinical Data

This section focuses on the clinical aspects of the claim. - Diagnosis Codes: Enter Principal, Admit, and Secondary diagnoses. Supports ICD-10-CM search. - Procedures: Enter ICD-10-PCS codes and dates. - Conditional Sections: Sections like "OASIS Assessment" and "IRF-PAI" appear only when relevant modules (HHAG, CMG) are selected.

3. Bottom Section: Line Items & Actions

The bottom section handles the detailed line items and final processing. - Line Items: Add revenue codes, HCPCS/CPT codes, modifiers, units, and charges. - Additional Data: Enter specialized data points required for specific calculations. - Process Claim: Submit the claim for calculation.

Getting Started

  1. Select Modules: Choose the payment systems you want to run (e.g., IPPS, OPPS).
  2. Enter Data: Fill in the required fields. Use the "Load Test Claim" feature to start quickly.
  3. Process: Click "Process Claim" to view the results.

Next Steps