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.

Insurance Claim