Manually reconciling Claim Items

Manually reconciling Claim Items

The system will automatically update the claims item Status when they are paid or denied for payer sources that receive electronic remittances, but for most other payer sources claim items must be manually reconciled. A few payer sources like PRO BONO and SELF PAY never have electronic remittances but are automatically updated as written off or paid respectively. Most payer sources can be set to automatically be handled a certain way using the "BillSubmitType" option under Settings -> Facilities -> Facility -> Facility Payers -> Facility Payer. Claim Items that need to be manually reconciled will sit in Submitted status until they are reconciled.

Claim Item Result Types

Multiple claim item results can be added to a claim item, and results have different types:
  1. Payer - The payer paid this amount. If the payer is SELF PAY them the client paid this amount.
  2. WriteOff - We expected to get paid this amount, but we are giving up on getting it.
  3. Adjustment - We never expected to get paid for this amount.
  4. Deductable - The client paid this amount because they had not yet met their deductible.
  5. Copay - The client paid this amount due to their copay.
  6. NextPayer - This amount we are going to bill the client's next (secondary) payer. You can't add this type directly.
  7. Defunct - We are giving up on this attempt and trying again (rebilling). You can't add this type directly.

Manually reconciling a Claim Item

  1. Go to the Claim Items report option under the Reports main menu option.
  2. Click the Clear button to remove all default search criteria, select Submitted for the Status. You can optionally further restrict the search, such as to a specific payer source or time period. Click Search and the search results will appear.
  3. Double click on a Claim Item that you wish to manually reconcile and the Claim Item will appear.
  4. Scroll down until you see an Add button.
  5. Click the Add button and add a result. If the payer denied the claim make sure the result type is Payer and the Status is Denied. If you are writing off the claim item make sure the result type is WriteOff and the Status is Approved. The Payroll Percentage determines how much of the paid amount will be applied to the provider's next time sheet. Click Save to save your changes.
  6. Continue adding results until the due amount for the claim item is zero. ChartCaddy will then place this claim in Tentative status. Tentative means that the claim item has been reconciled but we haven't gotten the official/verified results back from the payer yet with an electronic remittance.
  7. If you expect to get back an electronic remittance for the payer you should leave the status as Tentative, otherwise you should select "Status Final" from the drop down when viewing the Claim Item and then click the Update button. Either way, if the system hasn't gotten an electronic remittance from the payer in a few weeks it will change the Claim Item status from Tentative to Final for you.