Submit an HMO Claim and Post Remittance

When a patient is covered by an insurer, the covered portion of their invoice is submitted to the payer as a claim, and the payer’s eventual response — what they approved, rejected, and paid — is posted back as remittance. This page follows a claims officer building a claim from an invoice, submitting it in a batch, and reconciling the money that comes back.

Who / when: the claims officer, after an invoice has been issued for an insured patient (see Turn Charges Into a Scheme-Priced Invoice). A claim is an invoice’s covered lines submitted to a payer; an HMO is a Health Maintenance Organisation and the NHIS is the National Health Insurance Scheme — both are payer schemes. Remittance is the payer’s settlement response. We’ll follow Ngozi, who handles claims.

1. Ngozi (claims officer) — opens the invoice from Bill → Overview (click the row to reach its detail) or works from Bill → Claims, and chooses “Create Claim”.
2. Ngozi — selects the payer scheme and the source invoice. The claim is created in the Draft state, with the coverage percentage and covered lines drawn from the scheme.
3. Ngozi — reviews the covered lines and coverage. This is the moment to confirm the claim reflects what the payer has agreed to cover before it leaves the building.
4. Ngozi — submits the claim to the payer (batch-submitting one or more claims together). The claim moves out of Draft and a structured claim bundle is sent; a per-payer claim bundle can be produced as a branded PDF for the payer’s records.
5. The payer — processes the claim and responds. The claim’s state becomes Approved, Rejected, or Pending-Info (the payer has queried it and needs more).
6. Billing Manager — when the payer remits, opens Bill → Remittance and posts the remittance, reconciling what was approved and paid against the submitted claims. Posting remittance is a privileged Billing Manager step, so the money landing back is recorded under the right authority.

Note

A claim covers only the covered portion of an invoice — the insurer’s share at their agreed tariff. Any patient co-pay or uncovered balance is collected separately at the cashier desk, in Take a Payment, Deposit or Refund.

Caution

If a claim comes back Pending-Info, treat it as live work, not a dead end — the payer is asking for more before they decide. Supply what they need and keep it moving rather than letting it age. The full set of states and how to drive each one is in Run the Payer Claims Lifecycle End to End.

What happens next

With remittance posted, the insurer side of the invoice is reconciled and any remaining patient balance is clear to collect. The complete payer lifecycle — every state from draft to remittance, queries and rejections included, with the claim bundle PDF — is documented end to end in Run the Payer Claims Lifecycle End to End.

Follow the trail

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• Related: Run the Payer Claims Lifecycle End to End · Turn Charges Into a Scheme-Priced Invoice