Claims Overview

In general how the system works is that providers add chart items to client's charts and then they digitally sign them. At that point administrators finalize the chart items and shortly afterwards (depending on how the organization is configured) a claim is generated for each chart item. Claims start out in Posted status, and then progress to Submitted, Tentative, and then Final. If the payer does not pay the expected amount the claim initially goes to Exception instead of Tentative. Since private payers (not OKHCA MCO payers) are billed much more than is expected to be paid, those claims always go to Exception instead of Tentative.

When rebilling claim items to the same payer or billing a claim to the next payer, some information is pulled from the existing claim item and submitted as part of the new claim item. All the information is pulled from the "Payer" type claim item result, and if there are multiple previous claim items or payer claim item results then the information is pulled from the most recent claim item and claim item result by billed date and result date respectively. If the claim is being voided or rebilled to the same payer then the ShortName is pulled from the previous claim item result and submitted in the new claim item as the previous claim/control number (ICN). The Billing Note and Attachment ID are always pulled from the previous claim item result if they exist. When printing the claim item the previous control number is placed in box 22, while the Attachment ID and Billing Note is placed in box 19.

In addition information is pulled from the client's payer information pages for each claim item, such as the client ID number. The name listed on the claim item is pulled from there as well since it may differ for each payer. The Plan Name, Group Name, Referring NPI, and Prior Auth Num is pulled, which corresponds to boxes 11, 11, 17, and 23 on the printed claim respectively.

Posted claims have not been sent to the payer yet. Most folks have billing set to happen automatically so therefore most of the time there should be few or no claims in Posted. The most common reason for claims being Posted is the system is waiting to combine several rebilled claims into one batch. The next most common (but very rare) reason is the system isn't sure what to do with the claim, so it sets it as Posted to attract attention. Therefore if a claim sits in Posted overnight then you should contact customer support and tell us about it.

Submitted claims have been sent to the payer, and while we might have received an acknowledgement, we haven't received a definitive approval or denial yet. The main issue with Submitted is we should hear back from the payer within a few weeks, so if the billed date on a Submitted claim is more than a month ago then you need to do something about it. You should have automatic electronic remittances working which will help prevent this from happening. Failing that you should manually download and import electronic remittances into ChartCaddy from the payers regularly. Failing that you should manually verify that the payer received the claim and is in fact taking their sweet time processing it. There have been reports, especially with the OKHCA MCO payers, where we get an acknowledgement that the claim was received but then the payer swears they never got it. In that case there is not much you can do about it but rebill the claim, but you should rebill one or two first and work with the payer to make sure they got those, and then rebill the rest.

Exception claims are where the payer denied, underpaid, or overpaid the claim. For each claim you have to figure out what the problem is, whether it can be fixed, and whether or not it is worth the effort to fix it. If it is something on your end you can try fixing the chart item (if necessary) and then rebill the claim item. If it is something on the payer's end then you need to talk to them. Your basic options are to rebill the claim to try again, or to get the due amount to zero by adding a payment, adjustment, and/or write off. It is very difficult to get paid for services performed more than 180 days in the past, so it is probably best to just write off any exceptions older than that. Once a payer pays anything it is usually all they will ever pay for that claim item, so it is probably best to just write those off as well. Once the due amount of a claim is zero it's status automatically changes to Tentative. Claims will sit in Exception until they are manually processed. Ideally administrators should resolve all exceptions on a weekly basis.

Tentative claims are claims that were either paid in full or adjusted to have a due amount of zero. When a claim is rebilled the due amount for the original is adjusted to zero and it's status is set to Tentative. If and when the claim shows up on an electronic remittance its status goes from Tentative to Final. By default if a claim doesn't show up on a remittance it will automatically go to Final after five weeks, but that can be disabled if requested. If the Billed date of a Tentative claim is more than two months ago you should manually set the status to Final.