Insurance Claims
Create insurance claims by grouping pending invoices per insurance company
Overview
Insurance claims in SehaFile bundle multiple pending invoices for a specific insurance company into a single claim document. This allows you to submit grouped billing to insurers efficiently, track claim statuses through the full lifecycle (draft, submitted, under review, approved, paid, or rejected), and manage the financial reconciliation of insured patient services.
Creating an Insurance Claim
- Navigate to Claims: Go to Insurance > Claims from the sidebar and click + New Claim.
- Select Insurance Company: Choose the Insurance Company from the dropdown. Only companies with pending invoices appear.
- Select Invoices: The system displays all invoices for that company with insurance_status = "pending_claim". Check the invoices you want to include in this claim.
- Choose Branch (Optional): Filter invoices by branch if needed.
- Add Notes: Enter any Notes for internal reference or to include in the submission.
- Create Claim: Click Create Claim. The system:
- Generates a unique claim number (format: CLM-YYMM-###)
- Calculates total claim amount from insurance shares of all included invoices
- Sets claim status to draft
- Updates all included invoices' insurance_status to "claimed"
Claim Status Lifecycle
Claims follow a defined workflow with valid transitions:
- Draft - Just created, can still add/remove invoices, can be deleted
- Submitted - Sent to the insurance company (records submission date)
- Under Review - Insurance company is processing the claim
- Approved - Full amount approved (records approved_amount)
- Partially Approved - Only some amount approved (records adjustment_amount)
- Paid - Payment received from insurance (records paid_amount and paid_at)
- Rejected - Claim denied (records rejection_reason)
- Appealed - Rejection appealed (records appeal_notes, returns to submitted)
Updating Claim Status
- Open the Claim: Click on a claim from the claims list to view its details.
- Click Update Status: Use the Update Status button and select the new status.
- Fill Additional Fields: Depending on the transition:
- Approved: Enter the approved_amount
- Paid: Enter paid_amount
- Rejected: Enter rejection_reason
- Appealed: Enter appeal_notes
- Confirm: Click Save. When a claim is marked as "paid", all linked invoices have their insurance_status updated to "paid".
Tip: Use the Claims Summary view (Insurance > Claims > Summary) to see aggregated amounts across all statuses: pending, approved, paid, and overdue.
Warning: Only draft claims can be deleted. Once a claim is submitted, it cannot be deleted - it must go through the rejection/appeal workflow.
Insurance claims list showing claim numbers, companies, amounts, statuses, and the create claim dialog with invoice selection
Frequently Asked Questions
Can I add more invoices to an existing claim?
Only while the claim is in "draft" status. Once submitted, the claim is locked.
What happens to invoices when a claim is rejected?
All linked invoices have their insurance_status updated to "rejected". You can then create a new claim with corrected information or appeal.
How do I know which invoices are not yet claimed?
Filter invoices by insurance_status = "pending_claim" in the Invoices list. These are ready to be included in a new claim.
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