> ## Documentation Index
> Fetch the complete documentation index at: https://help.clinikehr.com/llms.txt
> Use this file to discover all available pages before exploring further.

# File and track claims

> Bill an insurer for care your hospital has already delivered, then follow the claim through to approval, payment or denial.

export const StillStuck = ({topic}) => <div className="ck-callout ck-callout--note" role="note">
    <p className="ck-callout__body">
      <strong>Still stuck{topic ? ` with ${topic}` : ''}?</strong>{' '}
      Check <a href="/platform/help/troubleshooting">Troubleshooting</a> first —
      it covers the failures we see most often. If that does not resolve it,{' '}
      <a href="/platform/help/contact-support">contact support</a> and include
      your workspace name and the time the problem happened, so we can find the
      matching entry in your audit log.
    </p>
  </div>;

export const TaskHeader = ({before, time, after}) => <div className="ck-task">
    {before ? <div className="ck-task__cell">
        <div className="ck-task__title">Before you start</div>
        <p className="ck-task__body">{before}</p>
      </div> : null}

    {time ? <div className="ck-task__cell">
        <div className="ck-task__title">Takes about</div>
        <p className="ck-task__body">{time}</p>
      </div> : null}

    {after ? <div className="ck-task__cell">
        <div className="ck-task__title">When you're done</div>
        <p className="ck-task__body">{after}</p>
      </div> : null}
  </div>;

export const Path = ({steps = []}) => <span className="ck-path">
    {steps.map((s, i) => <span key={i} className="ck-path__step">
        {i > 0 ? <span className="ck-path__sep" aria-hidden="true">
            ›
          </span> : null}
        {s}
      </span>)}
  </span>;

export const Availability = ({editions = ['all'], plans, roles, note}) => {
  const list = editions.includes('all') ? ['clinic', 'pharmacy', 'lims'] : editions;
  return <div className="ck-avail" role="note" aria-label="Feature availability">
      <span className="ck-avail__label">Available in</span>

      {list.map(e => <span key={e} className={`ck-pill ck-pill--${e}`}>
          {EDITION_LABELS[e] || e}
        </span>)}

      {plans ? <span className="ck-avail__label">Plan</span> : null}
      {plans ? <span className="ck-pill ck-pill--plan">{plans}</span> : null}

      {roles ? <span className="ck-avail__label">Who</span> : null}
      {roles ? <span className="ck-pill ck-pill--role">{roles}</span> : null}

      {note ? <span className="ck-avail__note">{note}</span> : null}
    </div>;
};

<Availability editions={['clinic']} plans="Enterprise" roles="Owners, managers, accountants and billers" note="Needs the Insurance care area switched on." />

A claim asks an insurer to pay for care you have already delivered. **Insurance Claims** is your hospital's claim register: you prepare each claim here, send it to the payer the way you already do, and track its answer. Nothing is transmitted electronically to a clearinghouse from this screen — knowing that up front saves waiting for a transmission that will not happen.

<Path steps={['Sidebar', 'Insurance', 'Claims']} />

<TaskHeader before="The insurer added under Companies, its prices set, and the patient's policy on file" time="5 minutes per claim" after="A claim on the register you can track to payment or denial" />

## What you're looking at

The heading reads **Insurance Claims** with your hospital's name beneath it, and a refresh button and **New Claim** beside it. A row of tiles sits above the tabs: **Total Claims**, **Approval Rate**, **Total Claimed**, **Total Approved**, **Total Paid**, **Pending Claims**, **Denied Claims** and **Pending Appeals**.

Three tabs, each answering a different question:

| Tab           | Answers                                           |
| ------------- | ------------------------------------------------- |
| **Claims**    | Where is this claim now? Work the list by status. |
| **Analytics** | Which payer is getting slower, or denying more?   |
| **Activity**  | Who did what to this claim, and when?             |

The list carries **Claim #**, **Patient**, **Type**, **Service Date**, **Insurance**, **Amount**, **Approved**, **Status** and **Actions** — **Amount** is what you billed, **Approved** is what the payer allowed, and the gap between them is your write-off or your appeal. Above it, search on "Search by claim number or notes..." and filter by status, by type (**Outpatient**, **Inpatient**, **Emergency**, **Pharmacy**, **Laboratory**, **Radiology**) and by company.

**Empty state.** With nothing raised, or a filter matching nothing, the list reads **No claims found**. Opening a claim that has been removed shows **Claim not found** with a **Back to Claims** button.

### The statuses

| Status              | What it means                                    |
| ------------------- | ------------------------------------------------ |
| **Draft**           | Being prepared. Still editable.                  |
| **AI Reviewed**     | An automated check has run. Still yours to send. |
| **Ready to Submit** | Prepared and checked, not yet sent               |
| **Submitted**       | Sent to the payer                                |
| **Under Review**    | The payer is assessing it                        |
| **Approved**        | The payer has agreed an amount                   |
| **Denied**          | Refused                                          |
| **Paid**            | Money received against it                        |
| **Appealed**        | Being contested after a denial                   |

## Prepare the claim

The claim form opens as tabs you work through in order.

<Steps>
  <Step title="Create the claim">
    Select **New Claim**.
  </Step>

  <Step title="Basic Info">
    The patient, the encounter and the dates. This is what ties the claim to the care that was actually delivered, and it is what a payer checks first.
  </Step>

  <Step title="Items & Services">
    Every service, medicine and consumable you are billing for. Prices come from the payer-specific rates on the **Pricing** tab of the [Insurance dashboard](/hospital/insurance/overview), not from your standard fees.
  </Step>

  <Step title="Insurance & Diagnosis">
    The insurer, the patient's cover, and the diagnosis codes that justify every item. If the form says **No insurance information on file**, select **Add Insurance** and complete the **Add Insurance Details** dialog. An item with no supporting diagnosis is the denial you will spend next month arguing about.
  </Step>

  <Step title="Review & Submit">
    Read the whole claim back, then save it. You are told **Claim created successfully! Starting AI analysis...**, and an **AI Analysis** tab appears alongside the others.
  </Step>
</Steps>

## Check it, then submit it

A saved claim is a **Draft** — nothing has left the building yet.

<Steps>
  <Step title="Open the claim">
    Select it from the **Claims** list.
  </Step>

  <Step title="Run the check">
    On a draft, **AI Review** looks for gaps a payer would query. It is a prompt to look again, never a decision, and the claim still moves only when a person moves it. **Edit** is available while the claim is a draft.
  </Step>

  <Step title="Submit">
    Select **Submit Claim** — offered on a **Draft** or an **AI Reviewed** claim. You are told **Claim submitted successfully** and the status moves on.
  </Step>

  <Step title="Quote the approval">
    Where you obtained a [pre-authorization](/hospital/insurance/pre-authorization), quote it. An approved request is the fastest route through a payer's review.
  </Step>
</Steps>

Record the payer's decision when it arrives, and record the money when that arrives. A claim marked paid with nothing reconciled against it is a claim you have not actually been paid for.

## Who can do this

**Role** decides whether the screen opens. On Enterprise, an owner controls which roles reach **Insurance** under **Settings → Role Navigation**; accountants and billers reach it by default, alongside owners and managers, and a role with no rule of its own is unrestricted.

**Permission** decides what a person may do inside:

| Action                      | Who can do it by default           | Permission                   |
| --------------------------- | ---------------------------------- | ---------------------------- |
| Prepare and submit a claim  | Owner, manager, biller             | **File insurance claims**    |
| Record a payer's settlement | Owner, manager, biller             | **Add insurance payments**   |
| Pull what a payer covers    | Owner, manager, accountant, biller | **Request coverage reports** |
| See the money figures       | Owner, manager, biller             | **View financial dashboard** |

Enforcement is **opt-in per person**: a colleague never saved in the permissions sheet is unrestricted, and the sheet warns **"Saving starts enforcing"** before that changes. A **denied action is recorded**; an allowed one is not. Hiding **Insurance** from a role is a convenience, not a security boundary — and a figure that is not yours to see is withheld rather than shown as **0**.

## Check it worked

* The claim appears on **Claims** with a **Claim #**, the payer's name and a status past **Draft**.
* **Total Claimed** on the tiles has risen by the claim's amount.
* Nothing you meant to bill this month is still sitting as a **Draft**.
* When money arrives, the claim reads **Paid** *and* has a payment recorded against it.

## Common issues

<AccordionGroup>
  <Accordion title="No claims found, but we filed several">
    Clear the search box and set the status, type and company filters back to **All**, then refresh. A **Draft** is hidden whenever the status filter is set to anything else.
  </Accordion>

  <Accordion title="The patient's insurer is not in the picker">
    Add the insurer on the **Companies** tab of the [Insurance dashboard](/hospital/insurance/overview), then record the patient's cover from the claim form.
  </Accordion>

  <Accordion title="The claim price is not what we negotiated">
    Payer-specific prices live under **Insurance** → **Pricing**. Fix the rate there so every future claim is right, rather than overtyping each one.
  </Accordion>

  <Accordion title="There is no Submit Claim button">
    It is offered only on a **Draft** or an **AI Reviewed** claim. A claim already submitted has nothing to submit; a claim you may not file will not offer it either — see [Permissions](/platform/team/permissions).
  </Accordion>

  <Accordion title="The payer denied the claim">
    Read their reason against what you submitted. Most denials are a missing supporting diagnosis, a quantity beyond what the plan allows, or an item the cover excludes. Correct the record and re-submit rather than arguing the original.
  </Accordion>

  <Accordion title="The patient's cover has lapsed">
    They are self-paying for that visit. Raise an invoice instead — see [Billing](/hospital/revenue/billing). A claim against expired cover is a denial you can see coming.
  </Accordion>
</AccordionGroup>

## FAQ

<AccordionGroup>
  <Accordion title="Is the claim sent to the payer for me?">
    No. It is prepared and tracked here, and you send it to the insurer the way you already do. Marking it **Submitted** records that you sent it.
  </Accordion>

  <Accordion title="Can I edit a claim after submitting?">
    **Edit** is offered while the claim is a **Draft**. Once it has gone to the payer, correct the record and re-submit rather than quietly changing what they were sent.
  </Accordion>

  <Accordion title="What is the difference between Amount and Approved?">
    **Amount** is what you billed; **Approved** is what the payer allowed. The difference is what you either write off or appeal, which is why **Pending Appeals** has its own tile.
  </Accordion>

  <Accordion title="Do I have to run the AI review?">
    No. It is a check, not a gate — a draft can go straight to **Submit Claim**. The form works the same without it.
  </Accordion>

  <Accordion title="Where do I see denial rates across payers?">
    On the **Analytics** tab for a quick read, and in the **Insurance** report for volume, denials and aging over a period — see [Reports and analytics](/hospital/executive/analytics).
  </Accordion>
</AccordionGroup>

<StillStuck topic="a claim" />