Claim Maintenance
The Claim Maintenance module is where claims management and overview is conducted. In the Claim Maintenance module, you’ll be able to research and view the history of claims, manually review pended claims and override claim decisions.
This module is split into 3 separate sections indicated with tabs on the left hand of the screen. Each tab has corresponding tiles all related to the claim currently in view.
Module Layout:
BASE: considered the main tab and source for claim data. This is where you will search for claims to research, manually review and/or override. The tiles w/in the Base tile are explained below:
Claim Maintenance: the main tile where you will search for claims. This tile includes the claim header information that displays base consumer and provider info, received date, claim type, date(s) of service, etc.
Claim Lines: displays the individual claim line information on a claim including the itemized services and date(s) of service on a claim. Claim line info will refresh according to what claim header is selected under Claim Maintenance
Adjudication Lines: This tile will display each adjudication measure taken on a claim line and display the adjudicated amount, adjusted amount and whether or not the claim line approved. The adjudication details in this tile will refresh depending on what claim line is selected in the claim lines tile. Most importantly, this is where you will OVERRIDE or MANUALLY REVIEW a claim line.
Reason: this tile works in conjunction with the adjudication tile. This tile will display each adjudication decision rendered. This will also display the adjudicated amount, adjusted amount and adjudication reason (whether it approved or the denial reason). The Reason tile will also refresh depending on which claim line is selected.
Billing Details: refer to this tile to research billing details for this claim to NCTracks.
RESEARCH: the research tab is designed to display relative information regarding the claim that is typically stored in other modules in the system.
Claim Lines: this tile is pulled in from the claim lines tile on the Base tab to refer to easily without navigating back and forth between tabs. The claim lines displayed will depend on what claim header is selected from the base tile.
Authorizations: displays authorization information for the consumer identified on the claim.
Credit Memos: displays credit memo information when a CM is applied to a claim.
Insurance: displays insurance information for the consumer on the claim.
Provider Contract: displays provider contract information for the provider submitting the claim.
PATIENT: the patient tab is designed to display additional consumer information that will affect claim adjudication.
Claim Maintenance: this will populate with the same information found on the Base tab, allowing easy access to patient specific information for each claim.
Duplicate Claims: will display any duplicate claims submitted.
Diagnosis: displays diagnosis information for the consumer on the claim.
Target Pops: displays consumer target pop information.
Research Comments: notes section to record any comments regarding the claim that other staff would need to know.
TECH NOTES: database table structures
BASE Tab
CLAIM MAINTANANCE (TOP)
Probably the most common view that gives the most information about the claim header is the 3 view:
Max Count Limit: 50 – max amount of records the system will return
Total Records Fetched – number of records returned out of the 50.
Re-Adjudicate: If the claim approved in error, or any changes have been made in the system to change the end result of the claim, then you will click this to re-adjudicate the claim. An example reason would be if a service mapping was incorrect and has since been corrected. Additional examples would be if a service rate has changed or, perhaps, if a providers contract or provider profile needed to be updated in order for a claim to approve. An additional screen will pop up to document the reason for the re-adjudication.
Revert: you would click this option if a claim approved in error and you wanted to recoup the money. An additional screen will pop up to document the reason.
3rd view defined: (TOP)
Claim Header ID: Alpha assigned # to identify a claim
Received Date: the date the claim was received and processed in the system
Claim Type: type of claim submitted, indicated as:
PP – Portal direct data entry professional claim via CMS 1500 “Professional Portal”
PF – Professional claim submitted via 837p, “Professional File”
IP – Portal direct data entry institutional claim via UB-04, “Institutional Portal”
IF – Institutional claim submitted via 837i, “Instutional File”
IU – claim that was uploaded from prior system b/4 moving to AlphaMCS
Provider: the provider who submitted the claim.
NPI: displays the Provider NPI submitted on the claim.
Patient: displays AlphaMCS patient ID and patient name.
Principal DX: displays the principal diagnsosis of the consumer.
Admission DX: displays the diagnosis of the consumer during admission if provided.
Claim Amount: the total dollar amount the provider has claimed to be reimbursed for.
Patient Amount: will display the dollar amount that the consumer has paid out of pocket, if any.
OI Pmt: displays the amount that a 3rd party has already paid, “Other Insurance”
OI Payer: displays name of the 3rd party payer if provided on the claim.
Deleted: The deleted flag is used to easily identify if the claim was reverted. Claims are never “deleted.”
MyMCS Claim #: if a Portal claim (or DDE claim) then the UB-04 or CMS 1500 claim number will be displayed here.
Resub Ref #: if the claim is a replacement claim, then the referencing claim number will display here.
Under Audit: intended for future use to identify if a provider currently being audited for various reasons.
CLAIM LINES TILE (TOP)
The claim lines tile is used to look at each claim line from within a claim header. Remember that the claim line(s) displayed will be determined by which claim header is selected in the Claim Maintenance tile.
3rd view defined:
Claim Line #: a unique Alpha assigned number used to reference the distinct claim line entry.
Proc Code: the procedure code, or service rendered for reimbursement.
Procedure #: a unique Alpha assigned number used to reference the distinct procedure code.
Mod 1,2,3,4: fields used to identify the service modifier(s) when one is submitted on the claim.
From/To: used to display a single date or a range of dates of service.
Amount: the dollar amount the provider is claiming for the service rendered.
Units: displays the number of units the provider is claiming for the particular service.
POS: indicates the place of service the service was rendered.
DX Code 1: indicates the diagnosis code the claimed service is being rendered for.
DX Code 2: indicates a secondary diagnosis code the claimed service is being rendered for.
Rev. Code: displays the revenue code on the claim line (institutional claims).
Auth #: if consumer has an authorization for the service rendered, the referring number will display here.
PAT Ctrl #: a provider reference number a provider or clearing house can use to reference a consumer. Submitted via 837 and not an Alpha assigned number.
Line Item #: a provider reference number a provider or clearing house can use to reference a claim or specific claim line. Submitted via 837 and not an Alpha assigned number.
COB Reason: indicates the reason for the coordination of benefits.
COB Amount: indicates the dollar amount another payer has already paid on a claim or responsible for paying.
Rend. NPI: displays the rendering NPI submitted on the claim. Clinician NPI for clinician based services, Provider or Site NPI for non-clinician based services.
Taxonomy: displays the taxonomy code submitted on the claim.
Site: indicates the physical site name and location the service was rendered.
ADJUDICATION LINE TILE (TOP)
The adjudication line tile is used to reference each time a judgment or decision has been performed on a claim line and the action taken.
Appr. Amt: indicates the approved amount on the claim line
COB Amt: indicates the coordination of benefits or PML amount
CO Amt: indicates the contractual adjustment amount
Other Adj. Amt.: indicates any additional adjustments
Other Adj. Amt. Reason: indicates the additional adjustment reason.
Approved/Denied: final decision, one or the other.
Comments: any comments provided during manual adjudication.
Claim Amt: dollar amount claimed on the claim line.
Adj. Amt: the dollar amount adjudicated from the claimed amount, typically the contract rate difference amount.
Adjusted Amt: the amount adjusted from the claimed amount (Claimed – Contract Rate * Units).
Adj. Units: the number of units adjudicated.
Total Units: total number of units identified on the claim.
Status: the current status of the adjudication process: Approved, Denied, Manual Review Required.
Rate: current contracted rate per unit for the provider.
CM: displays the dollar amount of how much the approved amount was satsified by a credit memo.
Benefit Plan: displays the payer of the claim.
Paid Amt: total amount paid on the claim line.
Captitated: display either True for capitated or False for Fee for Service.
Pd Flag: either 0 for not yet paid on a check, or 1 for already paid on a check.
Check #: displays the EFT check number the claim line was paid on.
Check date: indicates the last date of the “Check To” date on the checkwrite schedule.
Auth ID: displays the authorization number if the claim adjudicated against one.
ADJUDICATION LINE TILE: CONT. OVERRIDE (TOP)
In order to override a claim, you will want to click the adjudication line from the adjudication tile and choose Update:
After update is chosen, the adjudication line changes to an editable field. The below screen shot displays the editable fields after scrolling to the right:
**NOTE**: When overriding a payment for a single adjudication line, ALL adjudication lines will be updated with new adjudication IDs. This is to keep all adjudication lines “together” when billing. The intent is to simplify reconciliation.
ADJUDICATION LINE TILE: CONT. Manual Review (TOP)
There are various reasons that a claim may need to be manually reviewed:
· If a service is marked as “Manual Review Required” in the Provider’s Contract.
· If a claim line amount exceeds the claim line limit set by the MCO. Typicaly $5,000
· ED Claims for revenue codes 0450-0459
· POS Emergency Room on professional claims and l bill type 0131 on Institutional claims
In order to manually adjudicate a claim, use your filter on the Claim Header tile. Change the status dropdown to Manual Review and click Search. Once you find a claim to adjudicate, drag over the Adjudication Line tile, click your 3 view and click the Adjudicate button:
Note: ICF claims (rev code 0100) with bill types ‘065_’, ‘066_’, ‘089_’, ‘65_’, ‘ 66_’, ‘89_’ will not pend due to the commonality of a high dollar amount.
REASON TILE (TOP)
The reason tile provides a more detailed display of the adjudication process. Remember that this tile will display the adjudication reasons for the claim line previously selected in the Claim Line tile.
3rd view display:
Billing Details Tile (TOP)
The billing details tile is used to refererence the action taken after being billed to the state. Main source for populating this data can be found in tb_og_837_header and tb_og_837_det.
Batch #: references the batch number where this claim was sent.
Adjudication #: the reference number used to identify this particular payment, referred as clm_num in the tb_og_837_det table.
Provider NPI#: references the providers NPI used to submit the claim to NCTracks.
Rendering NPI#: references the rendering NPI number submitted depending on Clinician Based vs. Non-Clinician Based.
Billed Amount: this is the actual billed amount submitted to NCTracks for payment after adjudication adjustments.
Paid Amount: the returned paid amount from NCTracks
Adjudication Amount: the amount out of the provider claimed amount that was adjudicated.
Check #: displays the check number after payment has been posted.
Taxonomy: displays taxonomy code used to submit to NCTracks.
OG 837 date: displays the date the 837 was submitted to NCTracks.
Check Date: refers to the checkwrite date the check was posted.
Paid Units: displays the total units billed for this claim.
Reason Code: will display the HIPAA reason code for the adjudication decision (blank if approved).
Remark Codes: will display the HIPPA reason code for the adjudication decision (blank if approved).
Follow up Status: displays the current status of the claim: Denial Accepted, Denial Rebilled, 835 Received, Waiting for Response and (rsn_cd) + ACCEPTED where rsn_cd = 'A7','42','45'
RESEARCH Tab (TOP)
The research tab is designed to give you quick access to consumer information that relates to claims submission. The intention is to have all relative data in one module, eliminating the need to move back and forth between modules, thereby streamlining workflow.
The Claim Lines tile is carried over from the Base tile to be used as a reference point when researching why claims adjudicated the way they did.
Credit Memos Tile Click here to jump to credit memo queries.
When a claim is paid with a credit memo, use this tile to lookup information such as the source of the credit memo, the claim line the memo was applied to and check ID the credit memo was satisfied on.
Claim Header ID: references the claim header ID where the credit memo came from.
Source Claim: references the source adjudication ID from the claim header where credit memo was applied from.
Applied to Claim: references the claim line where the credit memo was applied to.
Applied Adj ID: references the adjudication ID of the claim where the credit memo was applied to.