Claims submission
Submit a claim to an HMO and track its status until payment.
Overview
A claim sends a list of services performed for an HMO patient to the provider for reimbursement. Format and submission method depend on the provider's accepted format. The platform tracks every claim through approval and payment.
Prerequisites
- Owner, Admin, or Billing Staff role
hmo_modulefeature flag- An HMO-enrolled patient with a completed visit
Steps
Open Claims. Top nav → HMO → Claims.
Click "+ New claim".
Pick the patient. Search; only HMO-enrolled patients with billable visits show.
Select services to include. Procedures from recent visits; tick the ones to claim.
Verify amounts. System uses provider-negotiated rates. Override if special circumstances.
Attach supporting docs. X-rays, treatment plans, referrals — based on what the provider requires.
Save as draft. Status DRAFT — review before submitting.
Submit. Click Submit claim. Status flips to SUBMITTED. Provider receives via the configured channel.
Track status. Status moves through RECEIVED → IN_REVIEW → APPROVED / REJECTED / PARTIAL. Update manually or via provider's API.
Record payment when received. When the HMO pays, Record payment against the claim. The patient's balance for that visit reduces.
Expected outcome
- A Claim entry per submission, linked to patient, provider, services, attachments
- Status reflects current state with the provider
- Payments tracked against claim and patient balance
Troubleshooting
| Symptom | Likely cause | Fix |
|---|---|---|
| Submit blocked | Required attachments missing | Attach per provider's spec |
| Provider rejected | Coding error or eligibility | Read rejection reason; resubmit corrected |
Status stuck SUBMITTED for weeks | Provider not responding | Phone the provider; manually update status if needed |
| Claim partially approved | Some services rejected | Record partial payment; bill patient for balance |
| Claim duplicates | Re-submission of corrected | Provider tracks claim ID; re-submission references it |