Complete the setup required to enable DrCloudEHR to provide billing and claims management functionality. The application's Billing Rules engine, Claim Rules engine, and Contract Manager work together with the Billing Manager and Claims Manager to provide efficient claims processing.

You can use DrCloudEHR to generate and submit claims in HCFA or UB-04 format. You can also generate and submit Detailed Financial Transactions (DFT) in HL7 format.

This topic contains the following sections:

Configure Insurance Providers

Add details for each insurance payer you submit claims to. To submit claims electronically, you must create connections to the medical claims clearinghouses used by the insurance payers to both submit claims and receive payment notifications.

Add an Insurance Provider

Add details for each insurance company to which you submit claims, including information required to process claims electronically.

You can configure the application track actual charges and adjustments based on your contract with the insurance company. The application uses the amount specified in the Contract Manager to calculate payments and adjustments. For example, assume you submit a claim for $475 for a service, based on the amount specified for the service code. However, per your contract, the company only pays $425, leaving you with a $50 adjustment.

You can configure the application to post the amount the insurance company agrees to pay in the claim details in the customer report. You can also specify that the application posts the adjustment in the system.

  1. Click the Practice  tab. 
  2. In the left-hand navigation menu, expand the Administrative tab, and then select Practice.
  3. Click the Insurances link under Practice Settings at the top of the page.



  4. Click Add.



  5. Enter the name and contact information for the insurance company.
  6. Enter the Centers for Medicare & Medicaid Services (CMS) identifier, which the electronic claims clearinghouse uses to identify the insurance company.
  7. Select the insurance company's type.
  8. Select the electronic claims clearinghouse the insurance company uses from the Default X12 Partner menu, which lists all clearinghouses added in the system.
  9. Select the type of insurance.
  10. Select the Change Charge checkbox to post the amount the insurance company agrees to pay in the claim details in the customer report.
    The claim you submit to the insurance company includes the full fee associated with the service code.
  11. If you select the Change Charge checkbox, select the Auto Adjustment checkbox to post the adjustment amount in the system.
    You can also select the code to use to categorize adjustments, such as administrative adjustment or insurance adjustment.
  12. Enter the insurance company's Employer Identification Number (EIN), if applicable.

Modify the Default Electronic Remittance Advice Processing Settings

The default settings used to process ERA files are set at the practice level. If necessary, you can modify a default setting. Note that the default settings are applied to ERA files received from all insurers, unless you configure custom settings for specific insurance companies as outlined in the Configure Payer-specific Electronic Remittance Advice Processing Settings topic.

  1. Click the Practice  tab. 
  2. In the left-hand navigation menu, expand Feature Settings.



  3. Expand the Billing tab, and then click the ERA Processing Options tab. 

  4. Select each setting you want to modify.

    SettingDescription
    Claim Matching OptionsSelect criteria to use to match claim identifiers with identifiers in DrCloudEHR. The system matches the original claim identifier by default.
    Service Line Matching OptionsYou cannot modify the current default settings.
    Denial Adjustment Reason Codes

    Specify the status codes that indicate a claim was denied. An ERA file containing the specified codes will be marked as denied. 

    Note that you must also select the Denied Adjustment Reason option from the Denied Service Options menu to enable the denial process.

    Denied Service OptionsSpecify under what conditions a claim should be considered as denied. Denied claims appear in the Denials Manager.
    Move To Next Responsibility OptionsSpecify when to move claims to the next level of responsibility, such as to the patient's secondary insurance provider.
    Reversal Claim OptionsSpecify the status that indicates a reversed claim.
    Denied Claim OptionsSpecify the status that indicates a denied claim.
    ERA Handling OptionsSpecify how to process incoming ERA files.
  5. Click Save.

Configure Payer-specific Electronic Remittance Advice Processing Settings

If the default ERA processing settings do not apply to a specific insurance company, you can configure custom settings that determine how ERA files received from the insurer are processed by DrCloudEHR. 

  1. Click the Practice  tab. 
  2. In the left-hand navigation menu, click the Administrative tab, and then select Practice.
  3. Click the Insurances link under Practice Settings at the top of the page.

  4. Click the ERA Settings button.



  5. Click Add. 

  6. Select each setting you want to apply.

    SettingDescription
    Setting NameA unique name for the custom settings.
    Processing From and To datesOptional date range during which to apply the settings.
    Claim Matching OptionsSelect criteria to use to match claim identifiers with identifiers in DrCloudEHR. The system matches the original claim identifier by default.
    Service Line Matching OptionsYou cannot modify the current default settings.
    Denial Adjustment Reason Codes

    Specify the status codes that indicate a claim was denied. An ERA file containing the specified codes will be marked as denied. 

    Note that you must also select the Denied Adjustment Reason option from the Denied Service Options menu to enable the denial process.

    Denied Service OptionsSpecify under what conditions a claim should be considered as denied. Denied claims appear in the Denials Manager.
    Move To Next Responsibility OptionsSpecify when to move claims to the next level of responsibility, such as to the patient's secondary insurance provider.
    Reversal Claim OptionsSpecify the status that indicates a reversed claim.
    Denied Claim OptionsSpecify the status that indicates a denied claim.
  7. Click Save.

Manage Insurance Contracts

Use the Contract Manager to define details on your contract with each insurance company. Creating a contract defines a fee schedule that shows the actual amounts the insurance company pays you for services based on service code and modifier combinations. 

When you post insurance payments manually or electronically, you have the ability to see and flag items that were not paid according to your contract. This allows for more immediate claims follow up, knowledge of potential payer fee changes, and overall better accounts receivable management. DrCloudEHR also provides reports that allow you to analyze claims payments that may be incorrect, based on the actual amounts the insurance company pays as defined in the contract.

To add a contract definition for an insurance company, you add each service code and any applicable modifiers, along with the allowable amount that can be billed for the code/modifier combination.

  • Click the  Practice  tab. 
  • In the left-hand navigation menu, click the Administrative tab, and then select  Practice.
  • Locate the insurance company for which you want to create a new contract in the table. 
  • Click the Manage button in the Contracts column. The Contracts/Fee Schedule page listing existing contract for the insurance company appears.



  • Click Add.
  • Enter a name for the contract, the date on which the contract takes effect and optionally the date on which it ends, and the facilities or programs to which it applies.
  • Click the Contract Details button on the Add Contract/Fee Schedule page.
  • Select a service code, and then add the insurance-specific modifier codes and the actual amount the insurance company pays for the service. 
    You can enter up to four alphanumeric modifier codes, separated with a single space.
    • Click Add Item to add a new service code entry. To define multiple service code/modifier combinations for a single service code, select the service code again, and enter the required details on the new row. 
    • If you have already defined service code/modifier combinations for the insurance company using the Billing Rules feature, click the Import All Service Rule Codes button to choose the service code/modifier combinations to add to the contract details.
    • Click the Import Existing Contract  button to import details from an existing contract.
  • Click Save to save the contract definition.

Configure Connections to Insurance Providers

You must configure connections with each insurance provider you want to interact with electronically.

Configure an EDI Connection to a Claims Clearinghouse

To submit HCFA or UB-04 claims electronically to an insurance payer, you must configure an EDI connection to the medical claims clearinghouse the payer uses to process claims.

When you configure the connection, you can enter a link to a form describing the services offered by the payers that clearinghouse supports in the Payer Lookup Website field. DrCloudEHR adds a Lookup CMS Payer ID link to the page containing the details for each insurance company. 

  1. Click the Practice tab. 
  2. In the left-hand navigation menu, expand the Administrative tab, and then select Practice.
  3. Click the X12 Partners link under Practice Settings at the top of the page.



  4. Click Add New Partner.



  5. Enter the required information. The information should be provided to you by the clearinghouse. 
  6. Click Save.

Enable Electronic Submission of Detailed Financial Transactions (DFT) Claims

To submit DFT claims electronically to a processor, you must configure a connection to the processor the payer uses to process claims. 

When you configure the connection, you specify an upload folder on the processor's server. When you submit a claim, DrCloudEHR uploads the DFT message in HL7 format to the folder.

  1. Click the Practice tab. 
  2. In the left-hand navigation menu, click the Administrative tab, and then select Practice.
  3. Click the ADT/DFT Partner link under Practice Settings at the top of the page.



  4. Click Add New Partner.
  5. Enter the required information. The information, including the upload folder and the local inbound folder locations, should be provided to you by the processor. 
  6. Click Save.

Enable Electronic Payments

To receive electronic payments from insurance payers, you must configure a connection to the clearinghouse to download the electronic remittance advice (ERA) file containing details on payments and adjustments. As part of the connection configuration you specify a download folder on the clearinghouse server from which DrCloudEHR downloads ERA files on a scheduled basis. The application scans each file for payment and adjustment details, and automatically writes the data to the DrCloudEHR payment system.

  1. Click the Practice tab. 
  2. In the left-hand navigation menu, click the Administrative tab, and then select Practice.
  3. Click the ERA Partners link under Practice Settings at the top of the page.



  4. Click Add New ERA Partner.
  5. Enter the required information, which should be provided to you by the clearinghouse.
  6. Click Save.

Configure Billing Rules

Billing rules define how claims are created for closed encounters. Billing rules enable you to use a single service code category to include multiple code, modifier, and billing unit type combinations in a claim.  When you close an encounter and generate a claim, the application applies the values set in the billing rule to the claim.  

You can set any of the following parameters in a rule to specify claims the rule applies to:

      • Insurance payer name and type
      • Facility or program
      • Provider's education or certification level
      • Place of service (POS)
      • Patient's age range 

In addition to the service code the rule applies to, you can specify additional service code/modifier/billing unit combinations that are added to claims. 

Add a Billing Rule

You can add multiple service code/modifier/billing unit combinations to the rule. The combinations are included in claims the rule is applied to.

You can use an existing billing rule as a templates for a new rule. Search for the existing rule at the bottom of the Billing Rules page, make any modifications, and then add the new rule.

  1. Click the Practice tab. 
  2. In the left-hand navigation menu, expand the Administrative tab, and then click Billing Rules.
  3. Enter a descriptive name for the rule.
  4. Select the service code the rule applies to. The selected code appears in the table under Output Service Code. 



  5. Enter the starting date on which the rule takes effect.
    You can optionally enter an end date. If you do not specify an end date, the rule remains in effect.
  6. Optionally select additional parameters the rule applies to, such as the insurance payer name and type.



  7. Select or enter the parameters to apply to the primary service code in the row created for the service code in the table under Output Service Code, including modifiers and billing units.
    You can specify a maximum of four modifier codes, separated by a space, in the Modifier field. 



  8. Select additional service codes to include in generated claims from the Output Service Code menu.
    Each code you add appears in the table under Output Service Code. For each code you add, select or enter the parameters to apply.



  9. Click Add to save the billing rule.

Configure Claim Rules

Use Claim Rules to automatically populate fields on UB-04 and HCFA claim forms with required values based on insurance payer requirements. The assigned value for a field is taken from existing data within your DrCloudEHR system. You can optionally specify a value for a particular field on a claim form.

The application applies a claim rule when you submit a claim for payment. Until a claim rule is applied, the claim forms created when you generate a claim using Billing Manager are not final, as values set in the form change according to the claim rule. 

For each field in a form, you can specify the action to take if the value is missing. You can also specify an error message to send to selected staff members.

Add a Claim Rule

Create the claim rule definition, and then configure each claim form field to apply the rule to.

  1. Click the Practice tab.
  2. In the left-hand navigation menu, expand the Administrative tab, and then click Claim Rules.
  3. Click the Add button.
  4. Enter the information required to create the claim rule, including the claim form type and the insurance provider the rule applies to.
  5. Select the checkbox indicating how the application sends notifications to DrCloudEHR users:
    • Reminder:  Select to deliver notifications in the specified user's inbox using a system reminder. 
    • Message:  Select to deliver notifications in the message section of the selected user’s Inbox. 
    • Who should be notified?: Select the users or groups of users to send notifications to.
  6. Specify the users or groups who receive notifications.



  7. Click Save to create the claim rule definition. The Mapping Fields section loads below.
  8. Configure each field you want to automatically populate with data. Click Add Field to add additional fields to configure.



    • Verify that the Box Value field contains the name of the corresponding property in DrCloudEHR. 
      The application populates the field in forms based on the value set for this property.
    • Select the procedure to follow when an error occurs due to incomplete or invalid data:
      • Ignore, Generate Claim: Ignores the claim error and generates the claim. This option should only be selected if the defined criteria is not required.
      • Notify Staff, Do Not Generate Claim: Blocks the claim from being generated if the data is blank or invalid, and sends the specified error notification to staff members designated to receive notifications.
        This is the best practice for handling errors of unique data specifications required by certain payers and for certain facilities.
      • Notify Staff, Generate Claim: Sends the defined error notifications to selected staff, but also generates the claim for submission.
        This option might be used when the data value is preferred, but not required. 
  9. Click Save to save the claim rule.