Claim Readiness checks an insurance claim for common completeness and billing issues before submission. Private pay services don't receive a Claim Readiness status.
In this guide, we'll cover:
Understanding readiness statuses
Understanding what Claim Readiness checks
Reviewing selected claims
Understanding which claims can be submitted
Fixing common issues
Understanding readiness statuses
Ready: Required information is present and no warnings were found.
Warning: The claim can be submitted, but something should be reviewed first.
Blocked: The claim can't be submitted until the identified errors are corrected.
Not started: There isn't enough claim information to complete the review, so the claim needs attention.
Important: Ready doesn't guarantee payer acceptance or reimbursement. It means the claim passed Allia's checks before submission.
Understanding what Claim Readiness checks
Service charges: Missing charges or claim and service totals that don't match
Diagnosis: Missing or incomplete diagnoses and invalid links between services and diagnoses
Patient and insurance: Patient demographics, payer details, and member ID
Provider and facility: Provider identity, National Provider Identifier (NPI), payer, and service facility
Service details: Current Procedural Terminology (CPT) code, units, dates, modifiers, and other service details
Claim details: Place of service, claim frequency, and other required claim information
Billing review: An existing draft superbill, invoice, or payment that conflicts with the claim
Reviewing selected claims
To review selected claims:
From the left menu, select Billing.
Select Master Billing.
Open Unbilled Services.
Select the claims you want to review.
Select Review claims.
Review the issue shown for each claim.
Select the pencil icon for a claim that needs correction.
Correct the claim information.
Save your changes.
Return to Master Billing.
Review the claims again.
Understanding which claims can be submitted
When you submit a batch, Allia submits claims with Ready or Warning status. Claims with Blocked or Not started status remain selected so you can correct them without rebuilding the batch.
Note: If none of the selected claims can be submitted, the submit action remains unavailable.
Fixing common issues
Enter any missing charges, then make sure the service total matches the claim total.
Add the correct diagnosis.
Connect the diagnosis to the service line.
Complete the patient's insurance and member information.
Add the billing provider, NPI, and service facility.
Add missing CPT, date, unit, or modifier information.
Resolve an existing superbill, invoice, or payment conflict.
Note: If you can't open Unbilled Services or Claims, ask a practice administrator to give you access. You must be able to create claims to submit them.