Claims
Raising demand for revenue
Managing Revenue Cycle
The Claims tab within the Revenue Management module is the final checkpoint before your agency submits billing to insurance (or other) payers. This page aggregates all billable activities, validates them against payer requirements, and allows you to generate professional claims (such as the CMS-1500 form).
🚀 Key Actions
At the top of the Claims list, you have two primary administrative tools:
[UPLOAD CLAIMS]: Use this to manually bring in external claim files or batches for processing.
[SELECT FILEABLE CLAIMS]: This powerful tool automatically filters your list to show only those entries that have passed all validation checks and are truly "Ready to Bill."
📊 The Claims Management Grid
This grid provides a comprehensive look at every potential claim. Each row represents a specific service window for a member.
Member & Payer Info
DDDID: The unique identifier for the client.
1500 Form: Click View to see a digital preview of the generated CMS-1500 claim form for that specific entry.
Payer ID: Identifies the specific insurance company (e.g., NJ Medicaid or PENN NATIONAL INSURANCE).
Demographics: Includes Patient Name, DOB, and Gender.
Service & Authorization
Prior Authorization: Displays the auth number linked to the service. If this is missing, the claim will likely be denied.
Diag Code: The ICD-10 diagnosis code required for medical necessity.
Service Dates: The Task Start and Task End dates for the billing period.
Financials: Includes Auth Amount, Procedure Code (e.g., T2024 HI), and Total Charges.
⚠️ Claim Validation & Errors
One of the most critical features of this page is the Claim Errors column. The system performs a "pre-flight" check to ensure your claims won't be rejected for simple data omissions.
Common errors displayed in the current view include:
Missing Address Info: "Patient Address Line 1 can't be empty."
Formatting Issues: "Patient Last Name can only contain letters, commas, periods..."
Missing State/Zip: Required fields for clean claim submission.
Claim Status: Most entries begin as "Ready to Bill." However, if errors are listed in the red highlighted text, you must click View or go to the Members tab to correct the profile data before the status can progress.
🛠️ Navigation & Export Tools
Date Selector: Use the Select Date tool to switch between months (e.g., February 2026) to review current vs. historical claim batches.
Table Controls:
Column Visibility (): Hide or show specific data points like Error Codes or Response Status.
Export (📤): Download your claims list as a CSV or Excel file for external audit.
Filtering (): Quickly find claims for a specific member or payer.
The claims dashboard is the key interface if your agency is only using the Fieldworker Billing functionality, without necessarily utilizing the entire revenue cycle within the platform. The claims submitted from the Prior Auth dashboard (after being duly matched against a prior auth entry, and having an approved MT, for NJ Support Coordination agencies) will also be available in this dashboard.
The dashboard has the following columns.
DDD ID
Patient First Name
Patient Last Name
DOB
Gender
Prior Authorization (number, mandatory, and should be in a correct format)
Diagnosis Code (key validation if your payer is Medicaid)
Medicaid ID (key validation if your payer is Medicaid)
Task Start Date (mandatory)
Task End Date (mandatory)
Auth Units (mandatory)
Procedure Code (mandatory)
Procedure Code Modifier (mandatory)
Claim Errors (where available)
Notes
Claim Status (where available)
Response Status (where available)
Created Date (when the claim entry was added)
Last Response Date (received from payer)
Error Code (where available)
Error Description (where available)
📄 Accessing the CMS Form
The CMS Form Modal is a digital version of the standard CMS-1500 health insurance claim form. It is the final document reviewed and edited before a claim is submitted to payers like Medicaid for reimbursement.
From the Claims list, click the View link in the 1500 Form column for any specific member row. This launches the modal, allowing you to review or manually override the auto-populated data.
🔍 CMS Form 1500
The form is divided into several standard sections required for a "clean claim" submission:
1. Payer & Insured Information (Fields 1-11)
Payer Name/ID: Identifies the destination for the claim (e.g., NJ Medicaid / Payer ID: 12205).
Insured I.D. Number: The member's unique insurance identification number.
Patient Demographics: Includes Patient Name, Date of Birth, Gender, and Address.
[!NOTE]
If fields like "Address" or "City" are blank, as seen in the current view, they must be corrected in the Member Profile to pass validation.
2. Clinical & Authorization Details (Fields 21-23)
Diagnosis Codes (ICD-10): The primary and secondary codes explaining medical necessity (e.g., F70, Q992).
Prior Authorization Number: The pre-approved code required for the specific service window (e.g., 1551236698).
3. Service Lines (Field 24)
This section provides the line-item breakdown of the work performed:
Date(s) of Service: The start and end dates for the billing period.
Procedure Code & Modifier: The billing code (e.g., E2024) and any required modifiers (e.g., HI, 52).
Charges & Units: The total dollar amount and the number of units delivered for that specific code.
4. Provider & Billing Information (Fields 25-33)
Tax ID / NPI: The federal identification numbers for your agency and the rendering provider.
Patient Account #: The internal system ID for the member (e.g., 975684).
Total Charge: The sum of all service lines (e.g., $362.89).
🛠️ Actions
[SAVE]: Commits any manual changes made to the form fields. These changes are saved to the claim record but do not permanently update the Member Profile.
[CANCEL]: Closes the modal without saving changes.
[SEND] (Background): Once the form is validated and saved, use the green button on the main Claims page to batch and transmit the files to the clearinghouse.
Scrubbing Reminder: Red text in the background of your current screen indicates missing data. Always verify that Fields 5 (Address) and 33 (Billing Provider) are fully populated before clicking Save, as these are common causes for claim rejections.
🗺️ Fieldworker to CMS-1500 Mapping Table
This CMS-1500 Field Mapping Guide identifies exactly where the data on your insurance claims originates within the Fieldworker platform. If you see a mistake on a claim, use this table to find and fix the "source" data.
CMS-1500 Box #
Form Field Name
Source Location in Fieldworker
🛠️ How to Perform an Update
If you identify a missing or incorrect field while reviewing a claim in the Claims tab:
Note the Box Number: Identify which field is failing (e.g., Box 5 for Address).
Go to the Source: Navigate to the Member Profile for demographic data or Settings for agency-wide data (NPI/Tax ID).
Update and Save: Correct the field and click [SAVE].
Refresh the Claim: Return to the Claims page and toggle the date or refresh the page. The digital CMS-1500 Form will now reflect the updated information.
Electronic Submission: While this guide refers to the boxes on a physical form, the same mapping applies to the 837P Electronic Claim File sent to the clearinghouse. Ensuring Box 33 (Billing Provider) and Box 24 (Service Lines) are correct is the #1 way to avoid "Front-End Rejections."
This Claim Scrubbing Guide helps you resolve the red "Claim Errors" seen on the Claims page. Because the billing system pulls data directly from the member's file, these errors must be fixed at the source to ensure insurance payers don't reject your submissions.
🧼 Step-by-Step: Scrubbing Your Claims
📍 1. Navigate to the Source
Demographic and address errors cannot be edited on the billing page; they must be fixed in the Members module.
Click on Members in the sidebar.
Search for the member listed with errors (e.g., Andre Rios8 or David Arthur Smith).
Click the Edit (Pencil Icon) on the far right of their row.
📝 2. Resolve Name & Character Errors
Error: "Patient Last Name can only contain letters, commas, periods, hyphens..."
The Cause: A number or invalid symbol was accidentally included in the name (e.g., Rios8).
The Fix: In the Basic Information section of the Member Profile, remove any numbers or symbols from the First Name and Last Name fields. Ensure it matches exactly what is on their insurance card.
🏠 3. Resolve Missing Address Details
Error: "Patient Address Line 1/City/State/Zip can't be empty."
The Cause: Required geographic fields are missing from the profile.
The Fix: Scroll down to the Address section in the Member Profile.
Requirements:
Address Line 1: Must have a street number and name (cannot be blank).
City/State/Zip: These are mandatory for CMS-1500 claim generation. If the client is homeless or in a shelter, use the facility's verified address.
✅ 4. Syncing and Final Verification
Once you have updated the Member record:
Click [SAVE] at the bottom of the member's profile.
Return to the Claims tab.
Use the Select Date tool to toggle away and back to the current month to refresh the data.
Verification: The red error text should disappear, and the claim is now officially Ready to Bill.
Clean Claim Tip: Before clicking [SELECT FILEABLE CLAIMS], always scan the Claim Errors column. If any red text remains, the system will prevent that specific claim from being included in the batch to protect your "Clean Claim Rate."
The Upload Claims feature is a bulk-import tool designed for agencies that track service data in external systems or large spreadsheets and need to bring that data into Fieldworker for professional billing and CMS-1500 generation.
Instead of scheduling and completing every session individually within the app, this tool allows you to "drop in" hundreds of visit records at once.
Upload Claims
For companies/agencies, not utilizing full revenue cycle, the claims may be directly uploaded here.
Upload Claims
How to Upload
1. Download the template
2. Fill out the template
If using Excel, make sure to export or save as a .csv
3. Upload the file
Click the upload button and choose a file
The Claims dashboard applies several validations and verifies if a claim is ready to be submitted. This is done to ensure swift payment on the first submission itself. The dashboard also allows editing a few columns to correct validation errors. All validated claims can be easily submitted to your payer (Medicaid) using a single click.
🛠️ How the Upload Process Works
The process follows a specific workflow to ensure that external data is "scrubbed" and validated before it ever reaches an insurance payer.
1. File Preparation
Format: The system specifically requires a .csv (Comma Separated Values) file.
Data Structure: The file must contain the core "ingredients" for a claim: Member IDs, Dates of Service, Procedure Codes (e.g., T2024), Units, and Modifiers.
Mapping: The system matches the IDs in your file to the existing Member Profiles and Agency Settings in your account.
2. The Upload Step
As seen in your current Revenue Management view:
Click the UPLOAD CLAIMS button.
Drag your
.csvfile into the white dashed box or click to browse your computer.Click the blue [UPLOAD FILE] button to initiate the import.
3. Validation & Error Checking
Once the file is uploaded, the data is not sent to the payer immediately. Instead, it populates the Claims Table in the background:
Scrubbing: The system automatically checks the imported data against the Member's profile for errors (like the "Missing Address" or "Name" errors we documented earlier).
Missing Data: If your CSV is missing a required field (like a Diagnosis Code), it will appear in the Claim Errors column with a red warning.
4. Finalization
Correction: You can click View on any imported row to open the digital CMS-1500 form and manually fix details.
Submission: Once the errors are cleared, you can use the SELECT FILEABLE CLAIMS button to move these imported records into your official submission batch.
💡 Why use this instead of the Scheduler?
Backlog Entry: If you are migrating from an old system and need to bill for sessions from several months ago.
External Vendors: If you use a third-party app for specific therapy types but use Fieldworker as your primary clearinghouse for Medicaid.
Mass Adjustments: If a payer requires a mass resubmission of corrected claims.
Ensure your CSV file uses the exact Member Names or DDIDs as they appear in your Members list. If the names don't match, the system won't be able to link the service to the correct client, resulting in an "Unknown Member" error.
To ensure a successful upload to the Revenue Management system, your CSV file must follow a specific structure. The system uses these columns to "map" your external data to the correct Member Profiles and Billing Settings.
📄 Sample CSV Template Structure
You can create this in Excel or Google Sheets and then save it as a Comma-Separated Values (.csv) file.
DDDID
First Name
Last Name
DOB
Gender
Prior Auth
Diag Code
Start Date
End Date
Units
Proc Code
Modifier
Total
987654
John
Doe
05/12/1985
M
PA123456
F70
03/01/2026
03/01/2026
4
T2024
HI
120.00
123456
Jane
Smith
11/22/1990
F
PA654321
Q992
03/02/2026
03/02/2026
2
H2015
U4
65.50
🔍 Column Definitions & Requirements
DDDID / Member ID: The unique ID assigned to the client. This must match the ID in your Members list exactly.
First & Last Name: Use plain text only. Avoid numbers or symbols (e.g., use "Jane," not "Jane2").
DOB & Dates: Use the format MM/DD/YYYY (e.g., 03/20/2026).
Prior Auth: The 10-digit authorization number provided by the payer.
Diag Code: The ICD-10 diagnosis code (e.g., F70). Do not include decimal points if the payer requires a consolidated code.
Proc Code: The 5-character HCPCS/CPT code (e.g., T2024).
Modifier: Any 2-character modifiers required for the service (e.g., HI, 52, U4).
Total: The final dollar amount for that specific service line.
🛠️ Technical Tips for a "Clean" Upload
Remove Headers: While it's helpful to have headers while you work, some systems prefer you to remove the top row before uploading. If the Upload File tool fails, try removing the header row.
No Empty Rows: Ensure there are no blank rows at the bottom of your spreadsheet, as this can trigger "Missing Data" errors.
Plain Text: Ensure your "Total" column is formatted as a "Number" or "Currency" in Excel, but without the dollar sign ($) symbol.
Character Encoding: Save your file as CSV (UTF-8) to ensure special characters (like hyphens in last names) are processed correctly.
Once you click UPLOAD FILE, the system will immediately check these columns against your database. If a DDDID isn't found, that row will be flagged as an "Unknown Member" error in the Claims list.
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