Your Contact Information

All ‘Contact Information’ fields are required in order to submit this service ticket.

Please fill in your first and last name, and the practice name for the claim that has been rejected.

Please fill in a valid email address that you have access to in order to receive service ticket updates as this issue is being worked on. If your email address is found in our system then you will automatically be assigned a service ticket number and you will receive an email confirmation.

Please provide the best contact number that you can be reached at and if this is an office phone, etc.

Your Medisoft Information

Medisoft Version:  Next provide us with information about your version of Medisoft, if you are not sure of the version you can select the Help menu in your Medisoft and then select About Medisoft.

Service Pack:  Indicate which service pack level you have installed.

Using Revenue Management?: Indicate if you are using Revenue Management to send your claims. Revenue Management is available with versions 17 and up. If you are using paper claims we only support the new CMS 1500 02/12 form that is available in versions 19 and up.

Revenue Management Updates Installed?: If you are using Revenue Management have you checked for updates and installed them?

Clearinghouse Information

Type of Claim:  Please let us know the type of claim that was rejected. Was this claim submitted in ANSI format (most commonly used in Revenue Management), or was it submitted on Paper, or as a Print Image.

Clearinghouse or Payer:  Select from the drop down list your clearinghouse or payer if not listed select ‘Other’ and the type the name in the ‘Other’ field that follows.

Claim Rejection Information

State the exact error message from your clearinghouse or payer. For better service if we could actually see the rejection that would help us to understand better. There is a place below where you can attach a copy of the rejection message if you have that in a file format such as a PDF file, etc.

Loop / Segment:  Most times a rejection message will include information about what loop and segment caused the rejection. For example if your claim was rejected for the wrong NPI number for the billing provider it would refer to ‘Loop 2010AA and Segment NM109’ If your rejection has that type of information please that in the field provided. As in our example above you would enter ‘Loop 20100 / NM109″.

What is Medisoft putting in the indicated Loop and Segment or field? A rejection message will usually tell you the data that is in error, as in our example above it would list the NPI number that was rejected.

What do you need to appear in the indicated Loop and Segment or field? If wrong information is being sent then we will need to know the right information so that we will be able to provide the correct resolution.

Chart Number:  Please provide the Medisoft chart number for the patient whose claim is rejected.

Claim Number:  Please provide the Medisoft claim number for the patient whose claim is rejected.

Date-of-Service on Claim:  Please provide the Date-of-Service for the patient whose claim is rejected.

Supporting Documentation

If you have a copy of the rejection from your clearinghouse that you can send this would help in the best resolution possible. There may be information indicated there that would better help us in understanding the issue that could not be explained in the steps above. Then please indicate whether or not you did include the attachment so that we have that documented.