Reimbursement Details in Healthie

Healthie makes it easy to track and manage claims from end-to-end. If you've integrated a clearinghouse with Healthie, such as ClaimMD, reimbursement details will automatically be updated when the ERA data is sent into Healthie.

Overview

To access reimbursement details:

• Navigate to Insurance > CMS 1500s
• Click the [...] next to a client claim > Reimbursement details

Within the Reimbursement Details section, you'll find the following information:

• Client Name and DOB
• Provider Name
• Status of the Claim (ie. Partially Paid, Fully Paid — see a description of all claim statuses here).
• Amount Billed — this is automatically calculated based on the billing details of the claim you submitted.
• Insurance Discount (if it applies)
• Reimbursement Amount and Date
• Amount client as already paid — you can manually enter the amount a client has paid prior to the claim being submitted.

Manually Create a Reimbursement

You can manually create reimbursement details for a claim at any time.

To access reimbursement details:

• Navigate to Insurance > CMS 1500s
• Click the [...] next to a client claim > Reimbursement details

From here, you can populate the following details:  

• Reimbursement amount and date
• Client paid amount
• Copay amount
• Notes (optional)

The Current Client Responsibility will automatically calculate, and you can alternatively remove the client responsibility altogether, or invoice for the client-owed amounts to keep your records clean.

Reimbursement Review & Adjustments  

Once the reimbursement details have manually or automatically populated, a modifiable reimbursement page will be accessible.

The reimbursement  has these parts:

• Header: shows the claim, client name, date of service, and provider name.
• Summary: the claim status and totals.
• Client payment: what your client has paid and still owe, with ability to add a client payment.
• Claim lines: one card for each CPT code on the claim, with the date of service, the billed amount, and the Post insurance payment and Write-off buttons (manually created or ClaimMD claims only)
• Show voided: a toggle that shows voided entries.

Review the Summary

The Summary card gives you the claim's current standing in four fields.

• Status: The claim status. See Tracking the Status of CMS 1500 claims in Healthie for every status.
• Billed: The total billed. Healthie calculates it from the billing details on the claim you submitted.
• Insurance paid: The total insurance has paid across all claim lines.
• Client responsibility: The amount your client owes.

Summary calculated from claim lines

• Computed totals: Healthie computes the status, insurance paid, insurance discount, and reimbursement date from the line payments below the Summary.
• Client responsibility: For line-level claims, Healthie calculates it from the client responsibility adjustments you or an ERA post to each line.

Record Client Payments

Use the Client payment card to record what your client has paid toward their share.

1. In Client already paid, enter any amount the client paid, for example before you submitted the claim.
2. In Copay still owed, enter the remaining copay. [CONFIRM: field definition]
3. Add a note in Optional notes, for example that you created an invoice.
4. Click Save client payment.

Current client responsibility shows the amount Healthie currently calculates your client owes.

Post an Insurance Payment to a Claim Line

Post a payment when a payer has paid or adjusted a specific service on the claim.

Payments and adjustments on a specific line

Post an insurance payment, with its adjustments, to the exact claim line the payer paid. Adjustments use Claim Adjustment Reason Codes (CARCs), the codes on your ERA that explain why a payer adjusted an amount.

1. On the Reimbursement page, find the claim line the payer paid.
2. Click + Post insurance payment on that line.
3. Select the Payer responsibility (Primary or Secondary)
4. Enter the Adjudication date.
5. Enter the Paid amount.
6. Optionally, enter the Allowed amount and Notes.
7. To record an adjustment, click + Add adjustment. Select the Group, for example CO, then enter the Reason code and Amount.
8. Save payment.

Notes

• Fields marked with a red asterisk are required: Payer responsibility, Adjudication date, Paid amount, and each adjustment's Reason code and Amount.
• To add more adjustments, click + Add adjustment again.
• To remove one, click the X button next to it.

The payment appears under the claim line with its payer responsibility, how it was posted (Manual), the date, the amount, and any adjustments, shown as the group, the reason code, and the amount. Repeat for each line the payer paid.

Available Group codes for adjustments:

• CO — Contractual Obligation
• PR — Patient Responsibility
• OA — Other Adjustment
• PI — Payer Initiated Reductions

Reason Codes can be reviewed here.  

Post a Write-Off to a Claim Line

Use a write-off to remove an amount from a specific service that you will not collect. The write-off reduces the balance of that billing item.

1. Find the claim line.
2. Click + Write-off on that line.
3. Select a Reason: Timely filing, Contractual (uncategorized), Payer recoupment, Billing error, or Other.
4. Enter the Amount.
5. Optionally, enter Notes.
6. Click Save write-off.

Reason and Amount are required.

The write-off appears under the claim line as Write-off with its reason, the amount, and how it was posted (Manual). Click Void to remove it.

Void a Payment or Write-off

Void a payment or write-off you posted by mistake.

1. Find the payment or write-off under its claim line.
2. Click Void on the right side of the entry. [CONFIRM: whether a confirmation prompt appears]

To see voided entries, turn on Show voided. They appear with a strikethrough and the label Voided.

To correct a payment, void it and post a new one.

Reconciling Client Owed Amounts

Most commonly providers will invoice clients and/or charge their payment card on file to collect any client owed amounts such as copays, deductibles, or declined charges.

As best practice, we recommend creating an invoice and associating it with the client CMS 1500. When creating an invoice for a specific claim, the client-owed amount will automatically populate into the invoice.

How to invoice a client for a client owed responsibility:

• Navigate to Billing > Payments > Invoices
• Invoice Type — select CMS 1500
• Recipient — select the client
• CMS 1500 — select the corresponding claim (submission) date
• Client Responsibility — this will automatically populate based on the Reimbursement Details for the claim.

Optionally, you can choose to write-off the claim (ie. in the event of a billing error).

Once an invoice has been created, you'll see a record of it under Payments > Invoices.

You can also use the option Notes section of the Reimbursement Details as a reminder that an invoice was created for this charge.

Once the invoice is paid, the client owed amount will be fully resolved and the claim status can be updated to Fully Paid.

As part of your billing workflows, we recommend running the CMS 1500 Report regularly for your account and reconciling any unpaid claims.