Claim Analysis Steps - Standard Tasks

Task 01 Ins. Payment

> Downloaded Remmitance of the Insurance of this Claim.

> Applied the Insurance Payment in this claim.

Possible Issues:

> Remmittance is in US$0, I did:

> Reviewed Track Claim History that is copied in Follow Up Notes.
> Reviewed Payer Report that is upload in Docs.
> Called Insurance so the inquiry is in Follow Up Notes.
> The action plan did to achieve the Ins. Payment is (explain).

> Remmittance is not available yet, I did:

> Reviewed Track Claim History that is copied in Follow Up Notes.
> Reviewed Payer Report that is upload in Docs.
> Called Insurance so the inquiry is in Follow Up Notes.
> The action plan did to achieve the Ins. Payment is (explain).

Task 02 Pt. Payment

> Reviewed in Practice Fusion if this Pt. did a payment.

> Download Pt. Payments Docs.: Invoices in Square or Deposit Slips in Box.
> Renamed the Pt. Payment Doc. according to the nomenclature.
> Applied the Pt. Payment in the Payment Section.
> Uploaded the Pt. Payment file in Documents section.

Possible Issues:

> There´s no any Pt. Payment then the Pt. Note was written.

Pt. Note All Notes

> This Pt. doesn´t have Payment by share costs.

> There´s none Pt. Payment vs. amount that Pt. must paid.
> There´s a partial Pt. Payment vs. amount that Pt. must paid.
> In Practice Fusion appears a Pt. Payment but there isn´t a receipt or deposit slip.

Task 03 Follow Up Note (Final)

> Reviewed % of Payment vs Amount including Ins. & Pt. Payment.

> Updated the Claim Status in Charge Section.
> Updated Final Follow Up Notes:
These are the final options to close
> Paid in 100% of Amount.
the Follow Up Notes when the
> Paid w. >= 80% and < 100% of Amount.
Payment is in 100% or there´s no
> Paid w. >= 40% and < 80% of Amount.
more that we can do to get a better
> Paid w. < 40% of Amount.
level of Payment.
> Paid in US$0.

% Paym. Vs Amount Calculator

Amount: $115.24 Amount: $78.47 Amount: $200.00

Insurance Paym.: $54.42 Insurance Paym.: $41.00 Insurance Paym.: $83.81
Patient Paym.: $0.00 Patient Paym.: $0.00 Patient Paym.: $0.00
Total Paym.: $54.42 Total Paym.: $41.00 Total Paym.: $83.81
% Paym.of Amount: 47.2% % Paym.of Amount: 52.2% % Paym.of Amount: 41.9%
 Some Follow Up of Process

Today: 13-Oct-2023
Entered Date: 3-Mar-2023
First it´s important to know is the
Follow Up Date: 17-Apr-2023 Expired
claim is been processed in the
timeframe or if it is expired, so it
Timeframe 60 days: 2-May-2023
indicates us there is an issue pending
Timeframe 90 days: 1-Jun-2023
to solve w. the claim.
Timeframe 180 days: 30-Aug-2023

On Time
> When Follow Up Date is on time.

> Cases: without issues

> Do the tasks although Follow Up Date to the Ins. Payment Process is on time (aprox. xx Nov. 2023).
> Also there´s no Pt. Payment charged.
> Track Claim History, there´s no issue related like follow:
> Copy TCH.

> New Follow Up timeframe for the Ins. Payment ends on xx Dec. 2023.

> Cases: with issues

> Do the tasks although Follow Up Date to the Ins. Payment Process is on time (aprox. xx Nov. 2023).
> Also there´s no Pt. Payment charged.
> In Track Claim History there is a issue w. Payment:
> Copy TCH.

> Before claim was accepted by Ins., Track Claim History presents this codes:
> Copy TCH.
> How fix the claim to achieve the Ins. Payment (explain what you did).

> In Call Insurance they told us the solution to achieve the Payment so:
> Sent this Claim to the rigth Primary Insurance.
> Sent this Claim to a Secondary Insurance.
> Sent this Claim to the right ID. Payer by location.
> Sent the Claim matching the Diagnosis Codes with CPTs.
> Sent this Claim with another CPT code.
> Sent this Claim without a CPT code.
> Sent this Claim with a modifyer.
> Sent the Claim with the right rendering provider.
> Sent the Claim with the right billing provider.
> Sent this Claim with the right faciility.
> Sent the Claim with the prior auth.
> Sent the Claim with the right Pt. ID.
> Sent the Claim with the referral.
> Other unpaid reason (explain).

> In Call Insurance they told us there´s nothing more we can do to achieve the Ins. Payment because:
> Timeframe of resubmmit is expired.
> Cost of the Claim in charge of Pt.
> Under Capitation Agreement.
> Other Unpaid Reason (explain).
 Expired

> Cases: without issues

> Do the tasks because Follow Up Date to the Ins. Payment Process is expired (aprox. xx Sep. 2023).
> Also there´s no Pt. Payment charged.
> Track Claim History, there´s no issue related like follow:
> Copy TCH.

> New Follow Up timeframe for the Ins. Payment ends on xx Dec. 2023.

> Cases: with issues

> Do the tasks because Follow Up Date to the Ins. Payment Process is expired (aprox. xx Sep. 2023).
> Also there´s no Pt. Payment charged.
> In Track Claim History there is a issue w. Payment:
> Copy TCH.

> Before claim was accepted by Ins., Track Claim History presents this codes:
> Copy TCH.
> How fix the claim to achieve the Ins. Payment (explain what you did).

> In Call Insurance they told us the solution to achieve the Payment so:
> Sent this Claim to the rigth Primary Insurance.
> Sent this Claim to a Secondary Insurance.
> Sent this Claim to the right ID. Payer by location.
> Sent the Claim matching the Diagnosis Codes with CPTs.
> Sent this Claim with another CPT code.
> Sent this Claim without a CPT code.
> Sent this Claim with a modifyer.
> Sent the Claim with the right rendering provider.
> Sent the Claim with the right billing provider.
> Sent this Claim with the right faciility.
> Sent the Claim with the prior auth.
> Sent the Claim with the right Pt. ID.
> Sent the Claim with the referral.
> Other unpaid reason (explain).

> In Call Insurance they told us there´s nothing more we can do to achieve the Ins. Payment because:
> Timeframe of resubmmit is expired.
> Cost of the Claim in charge of Pt.
> Under Capitation Agreement.
> Other Unpaid Reason (explain).
Task 04 Task Status

Complete.

> When is charged the Ins. and Pt. Payment max. that we could achieve.
> When all tasks were done.

In Progress.

> When the Ins. or / and Pt. Payment are pending.

> When the tasks were done partially.

On Hold

> When you are waiting for an Ins. Payment from a Payer inside the timeframe to finish another task
at your own, this task is On Hold.
> When we need another proccess or person do a tasks to finish any own task, assign the task and
put own On Hold. Most common tasks needs:

> Pls Read the follow Notes to understand the case.

> This claim has a Eligibility issue (explain).
> Timeframe max. te reprocess this claim: (put the FUD90 days).

> Pls Read the follow Notes to understand the case.

> This claim has a Billing issue (explain).
> Timeframe max. te reprocess this claim: (put the FUD90 days).

> Pls Read the follow Notes to understand the case.

> This claim has a Front Desk issue (explain).
> Timeframe max. te reprocess this claim: (put the FUD90 days).

Not Started

> When a tasks is assigned and doesn´t depend to another.

Task 05 Pt. Notes - All Notes

In this section you have to write payments included in the Payroll, as Ins. As Pt. Payments.

Whithout Issues

> Pt. Payment paid on xx Mmm. 2023.

> Ins. Payment paid on xx Mmm. 2023.

With Issues

> Pt. Payment pending to pay.

> Ins. Payment pending to pay.
> Paid to wrong rendering provider.
> Refund by…
 Task 06 Claim Status

> This an option that you must change in Charge Section of the Claim, although some of them are
changed automatically by system. Also some status are transitory and some are definitive status.
> See the table description in the next page.

Type Claim Status Description

Transitory Appeal at Insurance This Claim/Charge(s) is being appealed by the payer.
Transitory Balance due Patient Outstanding Claim/Charge(s) balances with this status are
added to the patient balance and are included in patient
statements.
Definitive Capitation Agreement Claim that is cover by Capitation Agreement.
Transitory Case Review at Insurance Case Review in process or paid partially and reprocessed.
Definitive Case Review Paid Case Review paid by Insurance.
Transitory Claim at Insurance The Claim/Charge(s) is at the payer. Claims/Charges are
automatically set to this status after being sent to the payer
or printed from the application.
Transitory Collection When a Pt. owes a balance and it´s pending to collect it
w. a collection date.
Transitory Cooinsurance due Pt. An specific kind of Pt. Payment in balance due Pt.
Transitory Copay due Pt. An specific kind of Pt. Payment in balance due Pt.
Transitory Deductible due Pt. An specific kind of Pt. Payment in balance due Pt.
Definitive Deleted Deletes the Claim/Charge(s) upon saving the claim.
Definitive Denied at Insurance The Claim/Charge were denied by the payer. Claim was
processed by Ins. and they considered it unpayable.
Transitory Incomplete The Claim is not complete and will not leave the system.
Claims will automatically be set to this status if the claim or
patient record are missing required fields (Note: Users are
not able to manually set a charge to a status of incomplete).
Definitive Paid The Claim/Charge(s) has been paid in full of amount (100%).
Always implies a portion or a total charge paid by Ins.
Definitive Paid High Level The Claim/Charge(s) has been paid >=80% but less 100%.
Always implies a portion or a total charge paid by Ins.
Definitive Paid Medium Level The Claim/Charge(s) has been paid >=50% but less 80%.
Always implies a portion or a total charge paid by Ins.
Definitive Paid Low Level The Claim/Charge(s) has been paid less 50%.
Always implies a portion or a total charge paid by Ins.
Transitory Paid in US$0 The Claim/Charge(s) has been paid in US$0 by Ins.
Transitory Paid with Info. Issues When Claim was paid but is requiered to solve info. issues
includying docs.
Transitory Pending Physician Hold status for Claims/Charges(s) that are pending the
office/provider.
Transitory Pending To Solve Info. Issues When Claim wasn´t paid or paid in US$0 and is required
to solve inf. issues includying docs.
Transitory Rejected at Clearinghouse The Claim/Charge(s) were rejected by the clearinghouse
and we have to fix sth.
Transitory Rejected at Insurance The Claim/Charge(s) were rejected by the Insurance
and we have to fix sth.
Transitory Remmittance Pending Upload Ins. Payment is approved and the remmittance is in line
to upload.
Definitive Self Pay When Pt. Pays the Claim/Charge(s) in full.
Transitory Send to Insurance via Clearinghouse Claim/Charge(s) will be sent to the payer according to
your Real Time Claim Submission Settings (RTCS).
Transitory Solve Info. Claim Issues We need fix info or send docs. to resummitt the claim.
Transitory User Print Mail To Insurance Claim/Charge(s) in this status can be printed individually
or in a group via the Claim Batch screen.
Transitory Waiting for Review The Claim/Charge(s) needs to be reviewed and status
updated before it will be sent to the payer. Claims created
via an interface will be left in this status.