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Submitting Claims to Candid Health

Medplum Provider can submit professional claims directly to Candid Health from a Visit's "Details & Billing" tab. Candid forwards the claim to the payer and reports its status back into Medplum. This video walks through the complete workflow, from billing setup to a submitted claim:


Prerequisites

The Candid Health integration is an enterprise feature. Please contact the Medplum team to have it enabled in your project. Once enabled, the billing feature on your Project turns on the Billing Settings page in Medplum Provider.

You should also be familiar with Visits and Care Templates, since Charge Items on a Visit are what populate the claim.

Overview​

Submitting a claim from Medplum Provider involves three stages:

  1. Billing setup (one time): register your billing organizations and rendering practitioners with Candid, and import the payers you bill.
  2. Patient setup: record the patient's insurance Coverage so it can be selected on the claim.
  3. Claim submission (per Visit): document the Visit, sign and lock it, review the claim, and submit it to Candid.

Under the hood, the app calls the $candid-submit-claim operation described in the Candid Health integration docs. That page documents the FHIR resources and identifiers Candid requires, which is useful if you are importing data or building your own front end.

Billing Setup​

Open Settings → Billing Settings (/Settings/Billing) in Medplum Provider. The page has four tabs:

  • Billing Organizations: the entities that bill payers. Each needs an NPI, a Tax ID (EIN), and a complete address. Saving an organization here also registers it with Candid as an organization provider. Payer contracts are still set up in the Candid portal; open an organization to see which contracts are active.
  • Billing Practitioners: the practitioners who render services. Each needs an NPI and a NUCC taxonomy code. Saving a practitioner registers them with Candid and links them as a rendering provider on the billing organization's contracts.
  • Payer Directory: search Candid's payer directory and click Import selected to save payers as Organizations in your project.
  • Enrolled Payers: the payers you have imported, with their identifiers and clearinghouse support. See Payer Directory for details.

Patient Coverage​

Before a claim can be submitted, the patient needs an insurance Coverage that points to one of your enrolled payers and carries the member (subscriber) ID. Add coverage from the patient's profile in Medplum Provider, or import it with the rest of your patient data.

You can also run an eligibility check against the coverage from the patient's Coverage page. See Eligibility Check for what the check returns.

Submitting a Claim​

  1. Document the Visit. Complete the Visit's tasks and questionnaires, then open the "Details & Billing" tab. Confirm the Charge Items generated by your Care Template, add at least one diagnosis, and select the billing organization.
  2. Sign and lock the Visit. The Submit Claim and Export Claim buttons are disabled until the Visit's chart note has been signed and locked.
  3. Review the claim. Click Submit Claim. The review dialog shows the patient, the rendering practitioner, the diagnoses, and the total. Choose Insurance pay and select the Coverage(s) to bill, or choose Self-pay if the patient is paying out of pocket.
  4. Submit to Candid. Click Submit to Candid. On success, the app saves a ClaimResponse with Candid's encounter and claim identifiers and shows a "Claim Submitted" notification.

After submission, the "Details & Billing" tab replaces the submit button with a claim status panel. It shows the Candid claim status, the submitted amount and time, and a View Claim on Candid button that opens the claim in the Candid portal. The status refreshes from Candid when you reopen the Visit, so you can track the claim from waiting_for_provider through to finalized_paid without leaving Medplum Provider.