Insurance Claims¶
The claims portal turns what the platform measures into claims the clinic gets paid for. It lives in the clinic area (Clinic › Claims) for clinic administrators, and in the admin panel (Operations › Insurance claims) for the platform team, which sees the same portal for any clinic.
Claims and coverage checks go through Stedi, a clearinghouse: the clinic is the billing provider on every claim, the platform submits on its behalf. Today the portal bills the remote therapeutic monitoring (RTM) codes the platform already measures (see RTM billing); the checks it runs are the foundation for helping clinics with other claims later.
Who sees it¶
| Clinic administrators | Platform admins | |
|---|---|---|
| Where | Clinic › Claims | Admin › Operations › Insurance claims, then pick the clinic |
| Needs | The claimsPortal flag on for the clinic |
Nothing; a clinic can be set up before its flag is on |
| Can do | Everything below, for their own clinic | Everything below, for any clinic |
Therapists and patients never see it. The therapists' own RTM Billing tab keeps working as before; a period a claim was sent for shows as Billed there.
Setup¶
Before the first claim:
- The clearinghouse. The platform team sets the Stedi key once for the whole platform. In test mode (the default) every coverage check answers with Stedi's sample data and every claim goes to Stedi's test environment, where it is checked exactly as a real one but never reaches a payer. The portal says which mode it is in at the top of every page.
- The clinic on the claim (Setup): the clinic's billing name, organization NPI, tax ID (EIN, or SSN for a solo practitioner), taxonomy code (225100000X for a physical therapist), street address with ZIP+4, and a phone number. Payers reject claims without any of these.
- Fee schedule: what the clinic charges for each RTM code (98975, 98977, 98985, 98979, 98980, 98981). This is the charge on the claim; the payer reduces it to its allowed amount.
- Defaults: the place of service (office, 11), the modifiers on every line (GP, which Medicare requires for services under a physical therapy plan of care), whether a period is billed on its last day or as a date range, and the filing limit after which the checks warn.
- Therapists: each treating therapist's individual NPI. A claim names the treating therapist on every line.
- Payer enrollment: payers that require it (every 835 remittance, some claims and eligibility checks) are enrolled per clinic NPI in the Stedi portal by the platform team. The payer search shows what each payer supports.
Patients¶
Claims › Patients lists every patient in care with their insurance, their last coverage check and what still stops a claim. Opening a patient shows:
- Insurance. The payer (found in Stedi's payer network by name or ID), member ID exactly as on the card, group number, plan type, and whether the patient is the policyholder. When they are not, the policyholder's details go on the claim as the insured.
- Coverage. Check coverage asks the payer in real time (an eligibility check) and shows whether coverage is active, the plan and group, coverage dates, copay, coinsurance, deductible and out-of-pocket amounts, whether prior authorization is flagged, and any other coverage the payer reports. Checks are kept, and the last answer counts toward the claim checks for 30 days. A check takes a few seconds, sometimes up to a minute.
- Details for claims. Date of birth, sex, address, the diagnoses the therapist treats (ICD-10-CM, the primary first), the day the patient agreed to remote monitoring, and the referring physician (Medicare asks for one on therapy claims). The consent date starts as the day the patient was added to the platform, the day the therapist set them up for monitoring, and says so under the field; change it when consent was given on another day. A claim with service before that day still warns that no consent date is recorded.
Fill from screenshots¶
Most of this already sits in the clinic's EMR. Fill from screenshots on a patient's page takes screenshots of the patient's record there, the insurance page, the patient page and the case with the diagnosis, up to six at once (PNG, JPEG or WebP): drop them into the window, choose the files, or paste a screenshot (Ctrl+V or ⌘V) anywhere on the page. The AI reads them once (they are not kept, by us or by the AI provider) and shows what it found: the payer, member ID, group number, plan and policyholder; the date of birth, sex and address; the diagnoses; the referral, or "direct access" when there is none; and anything worth knowing that has no field, such as an authorization rule. The payer is looked up in Stedi's network by the ID on screen, so the one Stedi bills is picked for you, or offered to confirm when only the name matched. Only the primary policy is filled in; a secondary one is listed.
Fill in the forms puts the values into the insurance and details forms, marked field by field, and nothing is saved until each form is saved. Check the marked fields: an identifier the AI could not read with certainty is left empty and named, a new payer's name with no payer ID on screen empties the old ID so the payer is looked up, and a name or date of birth that does not match the patient on the page stops the fill until you say the screenshots are theirs. After saving the insurance, Check coverage is the proof that the member ID is right with the payer.
To bill¶
Claims › To bill shows the RTM periods the platform measured that nobody billed yet, grouped by patient: each 30-day window with its days of data (98977 for 16 or more, 98985 for 2 to 15), the initial set-up (98975), and each finished month of management time with its minutes (98979 for 10 to 19 minutes, 98980 for 20 and one unit of 98981 per further 20). A month still running is not offered. The initial set-up (98975) appears once the patient has sent data on at least 2 days of a 30-day window: payers pay it only when monitoring actually started. With clinical documentation on, the signed visit notes are listed here too, one record per note with its codes and charges, priced from the visit fee schedule in Setup.
Each group shows what a claim would need and what stops it: no insurance, coverage not confirmed, a therapist without an NPI. A month of management time also needs the therapist to attest a live, two-way conversation with the patient that month: on the RTM tab (RTM Billing › Billable Codes) they tick Live call and confirm, which attests the month without marking it billed, so it stays here and can be sent. Until then that month waits on its own (it can't be ticked), and the patient's other periods can still be billed. Create claims builds one draft per patient from the selected periods. Nothing is sent and nothing is marked billed until the claim goes out.
The therapists under a patient's name, and See therapists next to "None of the patient's therapists has an NPI", open the patient's therapists. Each one shows their NPI, or that it is missing with the way to add it in Setup, and a therapist of the clinic can be added when the one who treats the patient isn't on the list. Add the therapist who actually treats the patient: new claims name them as the treating provider.
Claims¶
Every claim has a status:
| Status | Meaning |
|---|---|
| Draft | Built, not sent. Lines, diagnoses, place of service and the treating therapist can be changed. |
| Sending | On its way to Stedi; it can't be changed until Stedi answers (a few seconds). |
| Sent | Accepted by Stedi and on its way to the payer. |
| Accepted by payer | The payer acknowledged it (a 277CA). |
| Rejected | Stedi or the payer refused it before adjudication. Fix what they say and send it again. |
| Paid | The payer adjudicated it. Shows "Processed, $0 paid" when nothing was paid but nothing was denied either (for example, applied to the deductible). |
| Denied | The payer adjudicated it and paid nothing. The payer's reasons are explained on the claim. |
| Voided | Cancelled with the payer, or replaced by a correction. |
The checks¶
Before a claim can be sent it passes a list of checks, shown on the claim with what to fix and where. A blocker stops sending; a warning can be sent past once it was read. They cover:
- the clinic's setup and the therapist's NPI;
- the patient: name, date of birth, sex, address, diagnoses (format, specificity), consent, referring physician for Medicare;
- the insurance and the last coverage check (missing, inactive, older than 30 days, run in test mode, prior authorization flagged, other coverage reported, a member ID the payer spells differently);
- the claim itself: lines, units, charges, modifiers, diagnosis pointers, dates in the future or before the patient's birth, the filing limit, telehealth places of service for RTM;
- the RTM rules: 16 days for 98977 and 2 to 15 for 98985, the minutes behind 98979, 98980 and each 98981 unit, 98981 only with 98980, 98979 never with 98980 in the same month, an attested live conversation for the management codes, a device-supply code around management time, 98975 once per patient, no period billed twice, no overlapping device windows, no month of management twice.
A few things the claim says rather than asks: a Medicare patient's group number or plan name stays off the claim (Medicare has no groups and rejects both), and when a commercial plan has both a group number and a plan name on file only the group number goes out (a claim carries one or the other). This keys on the insurance type: when the coverage check answers as Medicare but the type is something else, the claim warns to set it to Medicare (Medicare Advantage stays "Commercial or other"). The payer and the member ID are what route a claim; the plan name never does.
Validate with Stedi runs the claim through Stedi's own edit library (thousands of payer rules) without sending it, and shows what would be rejected. It needs the production key, so the button is hidden in test mode; there Send runs the same edits and nothing reaches a payer.
The rules list¶
Every rule a claim is held to is listed under Rules in the admin claims portal (Admin → Operations → Insurance claims): the checks above, what the claim leaves out or shapes for a payer, and what To bill offers. Each rule says who it applies to (everyone, Medicare, remote monitoring, visit notes, corrections), how hard it stops a claim, where it comes from (the X12 guide, a CMS manual, a payer's rejection, the clinic's own policy, with a link where there is one), the day it was added, and any change since, with its date. Newest first, with a search box. Rules change, and payers reject for reasons nobody wrote down yet: when a rejection or denial teaches something new, the rule goes in dated, so the list is also the history of what the portal learned.
Sending and following¶
Send to payer runs the checks, builds the claim, sends it through Stedi, and marks the RTM periods behind it as billed on the therapists' RTM tab. Stedi answers at once: either the claim is on its way, or it was rejected with the edits that failed, in which case it stays editable and can be sent again.
From then on the claim is refreshed from Stedi twice an hour (and on Refresh status): the payer's acknowledgment, a rejection with its reasons, and the remittance (835) with what was paid, what the patient owes, and every adjustment code explained in plain words with the next step. Rejections and denials are counted on the overview.
Corrections and voids¶
A claim the payer has is frozen. Correct makes a new draft with the same lines, marked as a replacement of the original; Void makes one that cancels it. Either is sent like any claim. Both need the payer's claim number, which arrives with the remittance (Medicare claims can go without it). When the payer accepts the void or correction (its acknowledgment, or a remittance for it), the original shows as voided; Stedi passing it is not enough, since the payer can still refuse it. After an accepted void, the periods it billed are back in To bill (and no longer Billed on the RTM tab), so they can be billed again correctly, for example to the right payer. In test mode no payer answers, so a void stays Sent.
Good to know¶
- One claim per patient per selection; every line carries its own dates of service and the treating therapist.
- A claim number (17 characters) is made for every claim and comes back on every payer response; the lines carry it too.
- Claims sent in test mode are marked as test claims. Switching the key to production does not resend them.
- Money is tracked per claim: charged, paid, and the patient's share from the remittance (added up when a payer sends more than one, such as a reversal and a new payment). Nothing is posted to any accounting system.
- A patient with claims can't be deleted from the admin panel with the ordinary Delete: claims stay on record, and the dialog offers to set the account inactive instead. For a test account, Delete everything removes its test and draft claims (and its visit notes and plans of care) with the account, after a second confirmation. A real claim sent to a payer never goes.
- Medicare claims never carry a group number or a plan name; both can stay on the patient's record for reference, the claim leaves them off.
- Real-time claim status requests to payers (276/277) and electronic payments (EFT) are not part of this release.