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Claim Edits

Daniel Perlin
  • Updated

What is covered in this article?:

This article explains how to edit claims in Candid. In this article we will be covering the following workflows:

When to make edits to a single claim:

Candid users may need to edit a claim for a variety of reasons such as:

  1. The source encounter data was incorrect (i.e. a patient's member ID had a typo)
  2. New information was gathered from a provider or patient (i.e. a code received more documentation from a provider)
  3. An exception to a rule was identified (i.e. a certain payer has a non-standard telemedicine billing policy)

Generally, Candid users should add notes to explain their rationale for applying a bulk edit.

Subsequently, users should 1) make the necessary edits, 2) process the claim through the rules engine, and 3) submit / resubmit the claim in the same session. This ensures that the context of why the edit was made and how the claim should be processed is preserved.

How to make edits to a single claim:

STEP 1

Select the claim or claims you want to edit.

The fastest way to find a single claim is to use the search bar in the claims app and input a patient name or claim ID.

STEP 2

Find the field or fields you want to edit.

To avoid having to scroll through the whole claim, select the section of the claim you want to edit. In most coding use cases, this will be the Service Lines section. You can edit as many fields on a claim as you need to.

STEP 3

Check your advanced options.

Advanced options give you the control over how the rules engine applies to the claims you have selected. You should open this menu if you believe that the value you set in the claim edits workflow could be overwritten by the rules engine.

STEP 4

Action the claim

Once all your edits have been staged, click on the Actions menu at the top right of the claim and click either “Process & submit” or “Process & resubmit”. The claim will run through the rules engine. Please note that it is possible that the claim may not pass validations and another task may be created on the claim.

How to make edits to multiple claims at once:

What fields can I edit in bulk?

At this point, Candid has released support for bulk edits for the following fields:

  • Claim
    • Primary insurance
    • Secondary insurance
    • Place of service code
    • Service facility
    • Billing provider
    • Rendering provider
    • Pay-to address
    • CLIA number
    • Create service line
    • Split claim (also available in single claim actions)
    • Prior authorization number
  • Patient
    • Date of birth
    • Address
    • First name
    • Last name
    • Gender
  • Providers
    • Set referring provider
    • Delete referring provider
  • Primary Insurance
    • First name
    • Last name
    • Date of birth
    • Gender
    • Relationship to subscriber
  • Insurance Card
    • Payer
    • Member ID
    • Group number
    • Plan name
    • Plan type
    • Insurance type
  • Service Lines
    • CPT Code
    • Modifiers
    • Quantity
    • Billed amount
    • Drug identification
  • Referral number
    • Set referral number
    • Delete referral number

STEP 1

Select the claim or claims you want to edit.

This can be done using the filters in the Queues and Claims apps. You can edit up to 1,000 claims at a time. Only select claims that will have the same target value for your edit (for example, do not select a set of claims for which you want to edit a subset to Place of Service 10 and a subset to Place of Service 02).

STEP 2

Click on the actions menu and select “Edit and action”.

STEP 3

Choose the fields you want to edit and the action you want to take.

The fields that are available to be changed in bulk will be present in this menu. Candid is working on making more fields available in the near future! If a field you want to edit is not available here, it is likely it’s possible to edit on a single claim. Please see the steps above for single claim edits. Please note that you do not need to take a claim action in the same workflow as the edit, but it is recommended.

STEP 4

Set the new value for the edited field.

All claims you have selected will be edited to the same destination value.

STEP 5

Check your advanced options.

Advanced options give you the control over how the rules engine applies to the claims you have selected. You should open this menu if you believe that the value you set in the claim edits workflow could be overwritten by the rules engine.

STEP 6

Action the claim.

The action you selected previously will be pre-selected. Confirm that you still want to take the action on the selected claims.

How to make sure rules don’t overwrite your claim edits:

Claim Edits are designed to be as flexible as possible, but determining whether your claim edits are at risk of being overwritten by rules can be tricky. Many Candid customers set up Configurable Rules that are custom to their business and may inadvertently overwrite a claim edit. Some common examples are:

  1. A customer wants to edit a claim to have Place of Service 10, but has a telemedicine coding rule that sets Place of Service to 02 for all telemedicine claims for that payer.
  2. A customer wants to edit the payer, but has a BCBS routing rule routing claims to a default payer.

The Advanced Options menu in the claim submission modal will allow you to customize which rules will run on your newly-edited claims. If you know you do not want the field you just edited to be overwritten, you can select that field in the submission modal and all rules that affect that field will be skipped. 

A note on editing claim status, responsible party, and billable status:

Separate from claim edits, the following fields on a claim are used for reporting purposes and are also editable (though not yet in bulk):

Claim status

Claim status is generally a system-generated value. Changing claim status manually does not take action on a claim. Similar to claim edits, Candid users should generally change status and take action on a claim in the same session. Please see this article on editing claim status for more information.

Responsible party

Responsible party helps Candid determine the submission pathway for a claim. Changing the responsible party of a claim will change how Candid determines whether to bill insurance or invoice patients directly. Learn more.

Billable status

Changing the billable status of a claim will also help Candid determine the submission pathway. A claim that is marked as Not Billable will be excluded from A/R calculations (for both insurance and patient balances). Generally a claim with a Not Billable billable status should also have a Not Billable claim status. Learn more.

 

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