Manually Reconciling Claim Items

Manually Reconciling Claim Items

Overview

The system will automatically update Submitted claims item to either Exception or Tentative when they are paid or denied for payers that receive electronic status updates and/or remittances, but for some payers claim items must be manually reconciled. A few payers like PRO BONO and SELF PAY never have electronic remittances but are automatically updated as written off or paid respectively. Most payers can be set to automatically be handled a certain way using the "BillSubmitType" option under Settings -> Facilities -> Facility -> Facility Payers -> Facility Payer.

Submitted claim items normally stay Submitted forever, so if a claim item has a Status of Submitted and it's billed date is more than a month ago then you should probably manually reconcile it. Exception claim items will always stay in Exception forever until they are manually reconciled and should be manually reconciled on a regular basis.

Claim Item Result Types

Claim Items are adjusted by adding new or editing existing claim item result entries. Claim item results that have been reconciled may not be edited. Multiple claim item results can be added to a claim item, and results have different types:
  1. Payer - The payer paid this amount or the claim was denied. If the payer is SELF PAY then the client paid this amount. A claim item will stay in  Submitted status until one of these results is added.
  2. WriteOff - We expected to get paid this amount but we are giving up on getting paid. Claim items for services performed more than six months ago should be written off. This amount will be added to client invoices.
  3. Adjustment - We never expected to get paid for this amount, AKA contractual adjustment. This amount will not be added to client invoices.
  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 is the amount we are going to bill the client's next (secondary) payer. You can't add this type directly, it is derived from the claim item Due Amount when you select the "Next Payer" update option.
  7. Defunct - We are giving up on this attempt and trying again (rebilling). You can't add this type directly, it is derived from the claim item Due Amount when you select the "Rebill" update option.

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 or Exception 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 (if configured to) change the Claim Item status from Tentative to Final for you.