Document Submission Information

If necessary, click the Specific tab, then click New to display the Specific Claim Submission window.

Document the Submission information as follows.

Policy

Click the button to the right of the field and use the Select Policy window to search for and select the desired policy.

Claimant

Click the Claimant button and specify the claimant from the Account Claimant Search window. Note that the Claimant button only becomes active after you've picked a policy. If you need to manually create a claimant, click New in the Account Claimant Search window to display the Account Participant window.

First Name / Mid. Initial

Put the claimant's first name and middle initial in these two fields.

Last Name / Suffix

Put the claimant's last name and suffix (if any) in these fields.

Gender

Check the box corresponding to the claimant's gender.

Birth Date

When the claimant was born. Enter the date directly in the field in MM/DD/YYYY format or click the calendar icon and specify the date using the date picker tool.

Zip Code

Enter the claimant's zip code here.

Social Security No

Enter the claimant's social security number here.

Member No

Enter the claimant's membership number here.

Relation to Employee

Check the box corresponding to how the claimant is related to the employee.

Employee

If you checked any box other than Self for employee relationship, click this button and specify the employee using the Account Participant Search window.

Created

When the submission was created and by whom. Populated by ESL Office and is the current date and logged in user.

Administrator

Select the appropriate administrator from the drop-down.

Contract Basis

Policy contract basis. Populated by ESL Office based on your policy selection.

Deductible

Plan deductible. Populated by ESL Office based on your policy selection.

Submission

Specify whether the submission is a notification or reimbursement request by checking the appropriate box.

Received Date

When the claim was received. Enter the date directly in the field in MM/DD/YYYY format or click the calendar icon and specify the date using the date picker tool.

Created

When the submission was created and by whom. Populated by ESL Office and is the current date and logged in user.

If you checked Notification as your submission type, document the Notice of Loss as follows.

Notice Type

Specify the appropriate notice type from the drop-down.

Diagnosis

Check the box corresponding to the ICD codes you will be using for diagnosis information.

Primary ICD-9

Click the button and search for and specify the primary ICD-9 diagnosis using the Select Claim Diagnosis window.

Primary ICD-10

Click the button and specify the primary ICD-10 diagnosis. If you are using ICD-9 diagnosis codes (the ICD-9 box is checked), clicking the Primary ICD-10 button displays the Select ICD-10 Diagnosis window where you can select the corresponding ICD-10 code. If you are using ICD-19 diagnosis codes (the ICD-10 box is checked), the Select Claim Diagnosis window appears where you can search for and select the appropriate ICD-10 diagnosis. If you want to update the summary with the diagnosis, check the Update Summary box.

Secondary ICD-9

Click the button and search for and specify the secondary ICD-9 diagnosis using the Select Claim Diagnosis window.

Secondary ICD-10

Click the button and specify the secondary ICD-10 diagnosis. If you are using ICD-9 diagnosis codes (the ICD-9 box is checked), clicking the Secondary ICD-10 button displays the Select ICD-10 Diagnosis window where you can select the corresponding ICD-10 code. If you are using ICD-10 diagnosis codes (the ICD-10 box is checked), the Select Claim Diagnosis window appears where you can search for and select the appropriate ICD-10 diagnosis. If you want to update the summary with the diagnosis, check the Update Summary box.

Summary Diagnosis

Displays the diagnosis you selected above when you check the Update Summary box.

Total Paid Charges to Date

Enter total charges paid to date here.

Pended Charges by TPA

Enter any pended charges from the third-party administrator here.

Current Reserve

Current reserve. Populated by ESL Office based on your claimant selection.

Update Reserve

If desired, modify the reserve in this field.

Description

Provide a description for the reserve update here by clicking the button next to the field and specifying the reason from the Select Reason window.

Diagnosis Date

Specify when the diagnosis was made. Enter the date directly in the field in MM/DD/YYYY format or click the calendar icon and set the date using the date picker tool.

Date Last Charge Incurred

Specify when the last charge on the claim was incurred. Enter the date directly in the field in MM/DD/YYYY format or click the calendar icon and set the date using the date picker tool.

Large Case Management

Check the box corresponding to whether the claim falls under large case management.

If you checked Reimbursement Request, document the reimbursement request as follows.

Filing

Specify whether this is an initial or final claim by checking the appropriate box.

Diagnosis

Check the box corresponding to the ICD codes you will be using for diagnosis information.

Primary ICD-9

Click the button and search for and specify the primary ICD-9 diagnosis using the Select Claim Diagnosis window.

Primary ICD-10

Click the button and specify the primary ICD-10 diagnosis. If you are using ICD-9 diagnosis codes (the ICD-9 box is checked), clicking the Primary ICD-10 button displays the Select ICD-10 Diagnosis window where you can select the corresponding ICD-10 code. If you are using ICD-19 diagnosis codes (the ICD-10 box is checked), the Select Claim Diagnosis window appears where you can search for and select the appropriate ICD-10 diagnosis. If you want to update the summary with the diagnosis, check the Update Summary box.

Secondary ICD-9

Click the button and search for and specify the secondary ICD-9 diagnosis using the Select Claim Diagnosis window.

Secondary ICD-10

Click the button and specify the secondary ICD-10 diagnosis. If you are using ICD-9 diagnosis codes (the ICD-9 box is checked), clicking the Secondary ICD-10 button displays the Select ICD-10 Diagnosis window where you can select the corresponding ICD-10 code. If you are using ICD-10 diagnosis codes (the ICD-10 box is checked), the Select Claim Diagnosis window appears where you can search for and select the appropriate ICD-10 diagnosis. If you want to update the summary with the diagnosis, check the Update Summary box.

Summary Diagnosis

Displays the diagnosis you selected above when you check the Update Summary box.

Amount Requested

Enter the reimbursement request amount here.

Current Reserve

Current reserve. Populated by ESL Office based on your claimant selection.

Update Reserve

If desired, modify the reserve in this field.

Description

Provide a description for the reserve update here by clicking the button next to the field and specifying the reason from the Select Reason window.

Advance / Simultaneous Reimbursement

Specify whether the policy provides for advance or simultaneous reimbursement by checking the corresponding box.

Diagnosis Date

When the diagnosis was made. Enter the date directly in the field in MM/DD/YYYY format or click the calendar icon and set the date using the date picker tool.

Date Last Charge Incurred

When the last charge was incurred. Enter the date directly in the field in MM/DD/YYYY format or click the calendar icon and set the date using the date picker tool.

Large Case Management

Specify whether or not the claim falls under large case management by checking the corresponding box.

Manager Approval Required

Specify whether manager approval for the claim is required by checking the corresponding box.

Legal Complaint

Specify whether or not there is a legal complaint by checking the corresponding box.

Litigation

Specify whether or not there is litigation by checking the corresponding box.

Assignment Date

When the claim was assigned. Enter the date directly in the field in MM/DD/YYYY format or click the calendar icon and set the date using the date picker tool.

Auditor

Click the button and specify the auditor, if any, from the Auditor window.

Status

Claim status. Populated by ESL Office.

If you want to add any additional documentation to the submission as follows.

Comments

Enter any general comments regarding the submission in the text area.

Attachment

If you want to attach further documentation to the submission, click the Attachment button and select the desired file to upload.

Click Save to create the submission.