Creating a US Professional (CMS 1500) Claim

Every invoice you issue to an insurer becomes a claim in Pabau, pre-filled from the visit. The claim screen is a working CMS-1500: the same boxes a paper form would carry, laid out in sections you can open one at a time, validated against Claim.MD before anything leaves the building.

Step 1: Open the Claim

Go to Money → Claims and click the claim you want to work, or open the invoice and use the Claim.MD button in its header. Nothing needs creating first - an invoice issued to an insurer is already a claim.

The header carries the claim's status, the client and the payer. Below it, the form is split into sections, each showing how many fields still need attention.

Step 2: Check the Patient and Insurance Sections

These two sections fill themselves from the client record and the policy on file, so most of the time you are confirming rather than typing.

• Patient (boxes 2-5) - name, date of birth, sex, relationship to the insured, and address. Anything you leave blank falls back to the client record, so you only fill in what differs.
• Insurance (boxes 1a, 4, 7, 11) - Member / policy number and Group number, plus the insured's own details when the patient is not the policyholder. The payer itself comes from the insurer link you made in Setup.

Step 3: Confirm the Providers

The Providers section sets who performed the work and who sent the patient:

1. Rendering provider (box 24J) - pick the practitioner who saw the patient. The list comes from the NPIs you registered under Setup → Claims → Claim.MD → Providers, so a name missing here means the NPI has not been added yet.
2. Referring first name, Referring last name and Referring NPI - only needed when the payer requires a referral on the claim.

Step 4: Add the Diagnoses and Charge Lines

The Diagnoses section holds the ICD-10 codes for the visit (box 21), labelled A to D. Each charge line then points at the diagnoses that justify it.

Every charge line carries:

• Procedure (CPT/HCPCS) and Modifiers - comma separated where more than one applies.
• Units, Charge and Place of service.
• Diagnosis pointers (A-D) - which of the diagnoses above this line is billed against.
• First date of service and Last date of service.

Step 5: Fill In the Claim Details

The Claim details section covers boxes 10, 22, 23 and 27 - the situational fields that only some claims need:

• Accept assignment (box 27) - whether you accept the payer's allowed amount as full payment.
• Prior authorization number (box 23) - the payer's authorisation number. This prefills from the auth case attached to the booking, so it is usually already there.
• Resubmission code and Original reference no. (box 22) - paper resubmissions only. Electronic corrections set the frequency code themselves and ignore these two fields.

Step 6: Workers Compensation and Auto Claims

Workers comp and auto claims are billed to the carrier handling the injury rather than to the patient's health plan, so two boxes carry different values from a normal claim:

• Member / policy number - enter 999999999. Workers comp carriers do not issue a member ID, and this is the placeholder Claim.MD expects in box 1a.
• Group number - enter the carrier's claim or file number for the injury (box 11). This is how the carrier finds the case.

Then, under Claim details:

1. Set Employment related to Yes for a workers comp claim, or Auto accident to Yes for a motor accident.
2. Enter the Accident / injury date. This is required as soon as either box is Yes, and the claim is stopped before it leaves Pabau if it is missing.
3. For an auto accident, add the two-letter Auto accident state - the state the accident happened in, which prints in box 10b.

Step 7: Send a Chart Note With the Claim

Some payers, and most workers comp carriers, will not settle without the clinical note behind the visit. You can send one straight from the claim:

1. Attach the note to the client's case first (client card → Insurance → the case). It must be a PDF - Claim.MD accepts no other format.
2. On the claim, set Attach chart note from case to Yes - it sits in the same Claim details section shown above. This sends the case's newest PDF along with the claim.
3. Click Send Invoice to Claim.MD as usual.

The claim goes out carrying a reference to the document and its status becomes Held while the file is delivered. Once the note lands, the claim transmits to the payer by itself - no portal round-trip, no second submission.

Step 8: Validate, Then Send

Two buttons sit at the bottom of the claim:

1. Validate with Claim.MD - checks the claim without submitting it. Anything wrong comes back onto the field that caused it, with a plain-English explanation for the common cases.
2. Send Invoice to Claim.MD - submits the claim. The status moves to Submitted, or to Held when a chart note is attached.

Validating first is optional but cheap, and it catches the fixable problems before the claim is in the clearinghouse's hands.