Claim

Last updated: 2026-03-29

Claims Management

The Claims module handles the billing relationship between your facility and health insurance companies (such as those connected via Hakeem, JoFotara, or NPHIES). It allows you to request pre-authorizations, generate E-Forms, submit financial claims for reimbursement, and track whether a claim was paid or rejected.

When Do I Use This?

  • When an insured patient visits, and you need to get prior authorization or check their eligibility before providing services.
  • When a patient's visit is complete, and you need to submit the final medical bill (claim) to the insurance provider for payment.
  • When following up on pending claims to see if the insurance company has approved, paid, or rejected the submitted amounts.

How To Use

1. Requesting Authorization & Generating E-Forms

Before submitting a final bill, many insurances require an E-Form or Prior Authorization. The system automatically handles the specific rules for different payers (e.g., Medservice, Islamic, EuroArab).

  1. Go to Health Billing → Claims from the main menu.
  2. Open the specific claim document for the patient's visit.
  3. Click Generate References or Request Authorization.
  4. The system will communicate with the insurance portal. Once approved, the E-Form Number and Prior Auth ID will be automatically saved to the claim.

2. Submitting a Claim

Once the patient's visit is complete and all billing lines (medications, services, diagnoses) are entered:

  1. Open the ready claim.
  2. Review the Total Amount and individual Claim Lines to ensure accuracy.
  3. Click Submit Claim.
  4. The claim data will be securely sent to the insurance platform (e.g., JoFotara/Hakeem). The Submitted On date will be recorded.

3. Checking Claim Status

To see if an insurance company has processed your submitted claims:

  1. Open a submitted claim.
  2. Click Check Status.
  3. The system will securely check the provider's portal. It will update the claim's State (e.g., Paid, Rejected) and log the Resolved On date.

Field Descriptions

General Claim Details

Field Name Description
Reference / Name The unique internal tracking number for this claim (e.g., CLM1234).
Billing A link to the original patient billing invoice connected to this claim.
State The current status of the claim (e.g., Draft, Submitted, Authorized, Paid, Rejected).
Total Amount The total financial value being requested from the insurance provider.
Platform The integration portal handling this claim (e.g., Hakeem, NPHIES).
Submitted On The exact date and time the claim was successfully sent to the insurance company.
Resolved On The exact date and time the insurance company provided a final decision (paid/rejected).
Note Any internal notes or comments regarding this claim.

Claim Lines

These are the individual services, medications, or items being billed within the main claim.

Field Name Description
Billing Line The specific medical service or item provided to the patient.
Amount The specific cost requested for this single line item.
State The status of this specific line (sometimes an insurance pays for a doctor's visit but rejects a medication on the same claim).

Insurance / Hakeem Information

Special tracking numbers required by national health portals.

Field Name Description
E-Form Number The official electronic form number generated by the insurance (usually starts with JOR-F-).
Prior Auth ID The official approval code given by the insurance company to proceed with treatment.
TPO Transaction ID A technical receipt number from the insurance portal confirming they received your request.
Tip: If a claim is rejected due to a missing diagnosis code or incorrect patient ID, you can fix the error in the original Patient Billing record and use the Resubmit function. The system automatically tags it as a correction for the insurance provider.
Note: You do not need to memorize how different insurances work! The system is pre-configured to know that some payers (like Medservice) require an eligibility check first, while others (like Newton) auto-generate E-Forms. Just click Request Authorization and let the system do the heavy lifting.
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