The Medical Billing Queue

The Medical Billing Queue is an interface within Outcomes for pharmacies subscribed to Clinical Documentation or Medical Billing products. This tool allows pharmacies to view submitted medical claims and track the status of each claim.

Navigation

To access the Medical Billing Queue:

1. Log into your OutcomesOne account.
2. From the left navigation panel, select Service History.
3. Choose Medical Billing from the dropdown menu.

This will direct you to a comprehensive list of claims submitted by the pharmacy, displayed in chronological order, with the most recent claims shown at the top.

Page Overview

The Medical Billing Queue provides a detailed view of each claim, showing key information such as:

• Patient Name
• Date of Service
• Type of Service
• Rx Number
• NDC (National Drug Code)
• Medical Payer Information
• Patient's Medical Insurance Member ID
• Billable Codes on the Claim
• Status of the Claim
• Claim Amounts (Amount Billed, Amount Paid, Amount Adjusted)

Each field within the Medical Billing Queue can be sorted for easier management and viewing of data. Additionally, users can export all claim data into an Excel file for external review or reporting purposes.

Date Range Options

By default, the system displays claims from the past 30 days, but users can adjust this to view up to a year’s worth of claims history.

Claim Types

Claims are categorized into two distinct groups:

• Vaccination Claims
• Clinical Service Claims

Users can easily toggle between these categories at the top of the page, depending on which claims they need to review. You may only have claims information for one of these categories, depending on the medical billing services you have subscribed to.

Claim Statuses

The status of each claim is important in determining where the claim stands in the billing process. Below are the statuses you will see in the Medical Billing Queue and what they mean:

• New: The claim was received but has not yet been processed by Outcomes.
• Accepted: The claim has been accepted into the Outcomes billing process.
• Processing: The claim has been submitted to the medical insurance payer and is under payer review.
• Adjudicated: The payer has completed processing the claim.

Claim Payment Information

Once a claim reaches the Adjudicated status, pharmacies can reference key payment fields to see how the claim was processed by the payer:

• Amount Billed: The total amount billed to the payer.
• Amount Paid: The amount the payer agreed to pay.
• Amount Adjusted: The amount adjusted or denied by the payer.

These fields provide insight into the payment breakdown and can assist in determining any outstanding balances or patient responsibility. 

Medical Billing FAQs:

• What happens after I submit a vaccine or clinical encounter for medical billing?
  • When you submit a workflow for medical billing, our system will create a claim and send it to the patient’s insurance provider for payment. Payments for claims will be sent directly to your pharmacy or the location you’ve designated for receiving payments from the insurance provider. This process typically takes several weeks, from claim submission to payment by the insurance company. If any issues arise with the claim, our Outcomes team will handle them and will only contact you if additional information is required. 
• How will I be informed about my claim’s information?
  • When you subscribe to Outcomes Clinical Service or Medical Billing, you will have access to a status screen within the Outcomes system, where you can track your claims information. By selecting Service History in the Left Navigation, then selecting Medical Billing, you can see the status of claims submitted, including payment information and whether the claim is received, submitted, processing, or completed with the payer. You can also export this information for up to the past 365 days (about 12 months), making it easy to keep records or perform further analysis. 
• Are Clinical Workflow Medical Claims an MTM payable service?
  • No, clinical workflows are paid as medical claims, which are billed directly to the insurance carrier from the patient’s medical insurance policy.  
• Are Clinical Workflow Medical Claims reported with MTM Claims?
  • No, Clinical Workflow Medical Claims are not reported with the MTM Claims and have their own reporting mechanisms through the Medical Claims status screen and Advanced Clinical Services screen. 
• Where can I view the status of my claims?
  • You can view the status of your claims through the status screen in the Outcomes system by selecting Service History on the left navigation, then selecting Medical Billing. This screen will provide comprehensive details on claim status, payment information, and more. Alternatively, you may also contact the insurance company directly to inquire about the status of your claims if desired. 
• What if I have a specific medical billing question or a question regarding my medical claim?
  • For more information, contact Outcomes customer service.