Marley Health - Insurance Claim

Introduced in Version 16

The Insurance Claim DocType facilitates the process of submitting a claim to an insurance company (Payor) for healthcare services rendered by the facility. It ties together treatment details, insurance coverage, billing, and reimbursement workflows.

To Create an Insurance Claim

Home > Healthcare > Insurance > Insurance Claim

1. How to Create an Insurance Claim

Insurance Claims are linked to Patient Insurance Coverages and can be created once the service has been invoiced.

Step-by-Step Process

1. Sales Invoice and Coverage Handling

• After Patient Insurance Coverage is created, when generating a Sales Invoice for the related service, the item will automatically fetch coverage details.
• On submitting the Sales Invoice:
  • A Journal Entry is created:
    • The coverage amount is debited from the Insurance Payor's account
    • And credited to the Patient’s account
• The remaining patient payable amount can be settled by creating a Payment Entry from the Sales Invoice.

2. Creating the Insurance Claim

• Go to Insurance Claim > New.
• Select the Payor, Mode of Payment, Patient, Insurance Policy.
• The system will automatically fetch all pending Patient Insurance Coverages into the Claims table.
• Click Save and then Submit the document.

3. Updating Claim Status

• Once the Insurance Payor processes and responds to the claim:
  • Select one or more coverages from the Claims table.
  • Click on Update Claim Status.
  • Choose the appropriate status (e.g., Approved, Rejected).
  • The selected Patient Insurance Coverage documents will be updated accordingly.

4. Receiving Payment from Payor

• After the claim is approved, click Create Payment Entry to record the payment received from the payor.