ClaimRev Support Documentation

This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong.
====== Patient Coverage on Claims ======

ClaimRev now answers a question your claims could never answer before: **did this patient actually have coverage on the date of service?**

As each claim arrives, ClaimRev looks up the eligibility you have already run in **Sharp Revenue** for that patient, records what it found //on the claim itself//, and shows it on **Claim Search**. At a glance you can see whether coverage was active, whether it was with the payer the claim is going to, and whether the patient is a Qualified Medicare Beneficiary (QMB).

There is nothing extra to run. If your practice checks eligibility through Sharp Revenue, those answers are matched to your claims automatically.

<WRAP center round info 90%>
**Don't see a Coverage row on your claims?** The Patient Eligibility Check is switched on per account. See [[#turning_it_on|Turning It On]] at the bottom of this page, or contact ClaimRev.
</WRAP>

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===== Coverage on the Claim Search Grid =====

In the **Patient Info** column of each claim row, below the member number, you will see a **Coverage:** line with an icon and a short label. Hover over it to see the full wording along with the reason, when there is one.

^ Label ^ Icon ^ What It Means ^ What To Do ^
| **Active** | Green shield with a check | Coverage was confirmed for the service dates, with the payer this claim is going to. | Nothing. This is the good case. |
| **QMB** | Amber shield | Confirmed coverage reports the patient as a Qualified Medicare Beneficiary. | Review before billing the patient for any balance. See [[#qmb_patients|QMB Patients]] below. |
| **Other payer** | Amber warning triangle | Coverage was confirmed for the service dates, but it belongs to a **different payer** than the one on this claim. | Check the Coverage tab. Either the claim is headed to the wrong payer, or you have found the patient's other coverage for secondary billing. |
| **Not confirmed** | Red shield with an X | Nothing was confirmed for these service dates. Either no eligibility check is on file for this patient, or the coverage found does not reach the service dates (for example, a policy that terminated). | Open the Coverage tab or the Errors tab to see which of the two it is. A denial is likely. |
| **Not checked** | Grey question mark | ClaimRev looked but could not ask. Most often this means your account has no eligibility on file to check against for this patient. | Nothing is wrong with the claim. |

<WRAP center round tip 90%>
**"Other payer" is the one worth learning.** Before this change, coverage confirmed against //any// payer would have read as a plain green "Active", which is misleading: the payer actually receiving the claim has no confirmed coverage for that patient, and that is a denial waiting to happen. It now gets its own state so you can see the difference.
</WRAP>

==== Why some claims have no Coverage row at all ====

Claims processed before this feature existed have no coverage answer recorded, so they show no Coverage row rather than a misleading "Not checked" on your entire history. Coverage appears on claims received from the day the check was switched on for your account.

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===== The Coverage Tab =====

Click the **Details** (info) button on a claim to expand it, then choose the **Coverage** tab. It appears only on claims that actually have a coverage answer.

==== The summary ====

^ Field ^ What It Shows ^
| **Checked** | When ClaimRev looked up this patient's coverage |
| **Service dates asked about** | The claim's service dates, which are what coverage was judged against |
| **Member ID used** | The member ID ClaimRev searched on |
| **Note** | One line explaining the result, when there is something to explain |

==== QMB banner ====

If confirmed coverage reports QMB status, a banner appears above the coverage cards. It is shown on its own rather than as one tag among many, because QMB affects how the patient's cost sharing is handled.

==== Coverage cards ====

Below the summary, each eligibility record that matched the patient gets its own card. The tags on the card header tell you what you are looking at:

  * **This claim's payer** or **Another payer**, so you can immediately tell whether the coverage applies to the claim in hand
  * **Not confirmed**, when the policy does not reach the service dates
  * **QMB**, when that record reports Qualified Medicare Beneficiary status

Each card then shows:

^ Field ^ What It Shows ^
| **Reported status** | Coverage status in the payer's own words |
| **Policy period** | The effective dates of the policy. An open end date means ongoing. |
| **Checked on** | The date that eligibility response came back |
| **Source** | Where the answer came from |
| **Matched on** | Which identifier matched this patient, and how |
| **Insurance type** | Insurance type codes returned by the payer |

If a record could not be confirmed, the reason is printed underneath in amber.

<WRAP center round info 90%>
The coverage recorded on a claim is a **snapshot** taken when the claim was processed. It stays as it was, so a claim always reflects what was known at the time, even if eligibility is re-run for that patient later.
</WRAP>

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===== Coverage Warnings on Claims =====

When coverage cannot be confirmed, the Patient Eligibility Check adds a message to the claim's **Errors** tab. There are two, and they mean different things:

^ Message ^ What It Means ^
| **NO ELIGIBILITY CHECK ON FILE FOR THIS PATIENT** | Nothing has been run for this patient. Very often this simply means you do not run eligibility for that payer. |
| **ELIGIBILITY FOUND BUT NOT CONFIRMED** | Something was found and it does not hold up: terminated coverage, or a policy that does not reach the service dates. The payer's own reason is included in the message. |

**By default both are warnings, and a warning never holds a claim.** Your claims keep flowing exactly as they do today. The warning is there so you can see the risk before the payer tells you about it.

==== Clearing and ignoring ====

  * An individual warning can be **ignored** on the claim, which records who dismissed it and why
  * All warnings raised by this check can be cleared from a claim **in one action**, rather than one at a time

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===== Making It Stricter: Patient Eligibility Rules =====

Once you trust your own eligibility data, you can tell ClaimRev to **hold** a claim instead of just warning about it. Go to **Rules → Patient Eligibility**.

<WRAP center round important 90%>
**Rules here only change severity.** The Patient Eligibility Check has to be switched on for your account first, under **Rules → Modules**. Until it is, nothing on the rules screen has any effect.
</WRAP>

A rule has these settings:

^ Setting ^ What It Does ^
| **Start Date** / **End Date** | When the rule applies. Leave the end date blank to keep it running. Claims are judged against the rule that was in force when they were processed, so turning a rule on today does not change how last month's claims were treated. |
| **Payer Number** //(optional)// | Applies the rule to one payer. Leave it blank to apply to every payer. A payer-specific rule wins over the all-payers rule. |
| **No eligibility on file** | Warning or Claim Error, for the case where nothing has been run for the patient |
| **Coverage found but not confirmed** | Warning or Claim Error, for terminated coverage or a policy that does not reach the service dates |
| **Notes** | Why the rule exists. The next person to read it will want to know. |

==== Why two severity settings ====

The two findings are not equally serious, and most practices treat them differently.

"No eligibility on file" usually just means you do not run eligibility for that payer, so it is rarely worth holding a claim over. "Found but not confirmed" is genuine evidence the payer will reject.

A common setup is to hold on **not confirmed** while leaving **no eligibility on file** as a warning.

==== Start with one payer ====

Because a rule can name a single payer, you can hold claims for Medicare, where you run eligibility on every patient and trust the data, while everything else stays a warning. Add payers as your eligibility coverage grows.

**If you add no rules at all, everything stays a warning and no claim is ever held.**

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===== QMB Patients =====

When confirmed coverage reports a patient as a **Qualified Medicare Beneficiary**, ClaimRev flags it in three places: the **QMB** state on the claim row, the banner on the Coverage tab, and a **QMB** tag on the coverage record itself.

ClaimRev reports what eligibility returned. It does not make a billing determination for you, so review QMB status against your own policy and payer agreements before billing the patient for a balance.

QMB takes precedence over the "Other payer" state on the claim row. If a claim is both, the row shows **QMB**, because that is the one with consequences for the patient.

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===== Turning It On =====

The Patient Eligibility Check is enabled per account under **Rules → Modules**. If you would like it switched on, contact ClaimRev support and we will enable it for you.

Once it is on:
  - Coverage is recorded on every new claim as it arrives
  - The **Coverage:** row appears on those claims in Claim Search
  - The **Coverage** tab appears in the expanded claim detail
  - Coverage warnings appear on the Errors tab where nothing could be confirmed
  - Optionally, add rules under **Rules → Patient Eligibility** to raise those warnings to holds

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===== Tips =====

  * **The better your eligibility coverage, the better this gets.** Coverage on claims is only as good as the eligibility you have run. See the [[guides:sharp-revenue|Sharp Revenue guide]] for batch eligibility.
  * **Watch for "Other payer" on denials.** When a claim denies and the Coverage tab shows active coverage with a different payer, you have already found where it should have gone.
  * **Use it for secondary billing.** Coverage on another payer is exactly what you need to build a secondary claim.
  * **Start in warning mode.** Live with the warnings for a few weeks, see how often they are right for your payers, and then decide where to hold claims.
  * **Read the note, not just the icon.** "No check on file" and "coverage ended 01/31/2026" both show as **Not confirmed**, and they call for completely different follow-up. The difference is in the tooltip and on the Coverage tab.

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//See also: [[guides:claim-search|Claim Search]] · [[guides:sharp-revenue|Sharp Revenue: Eligibility & Patient Management]] · [[guides:claim-rules|Claim Rules Engine]]//

//Need help? Contact ClaimRev support at [[mailto:help@claimrev.com|help&#64;claimrev.com]] or call 918-842-9564.//