-Title of Module

The claims exceptions module is used by the MCO finance staff to manually associate a claim submitted via 837 to a Patient, Provider or a Site when this can not be systematically determined by AlphaMCS or if there is ambiguity across provider sites.

When Do Claims Appear in Claims Exception?

When claims are processed from an 837 file a patient ID, provider ID and site ID are assigned to each claim. If adjudication process cannot ascertain a clear and distinct Patient, Provider or Site ID for which the claim should be assigned then the claim will be flagged to be processed manually by the MCO staff on the Claims Exception screen. MCO staff will be able to assign to the Patient, Provider or Site ID to the claim manually at which point the claim will be queued for adjudication.

Example of Each

  • Patient: if claim data in the 837 matches on multiple consumersdue to duplicates that need to be merged or if a consumer cannot be matched based on 837 data.
  • Provider: if the NPI submitted on the claim is not recorded in AlphaMCS. Even if the NPI is completely wrong you would need to match to a provider so the denied claim will show on the the Provider’s RA to correct and rebill.
  • Site: a claim can go to claims exception if the NPI submitted on the claim and the zip+4 on the claim match multiple sites. More Scenarios

Priority Levels on Site Determination

When selecting a site, you will notice there are multiple priority levels to assist in matching a claim to a site. Priority is based on match strength, 1 being a distinct match up to 11 being the least likely match, but a match none-the-less.

Priority / Description
1 / Single sites and sites selected on portal claims
2 / Contracted site for multi-description codes
3 / Claim SFL NPI matches MCS site NPI, Claim SFL ZIP matches MCS site ZIP
4 / Claim SFL NPI matches MCS site NPI, Claim SFL ZIP matches MCS provider ZIP
5 / Claim SFL NPI matches MCS site NPI without any ZIP match
6 / Claim billing NPI matches MCS site NPI, Claim SFL ZIP matches MCS site ZIP
7 / Claim SFL ZIP matches MCS site ZIP without claim SFL NPI match
8 / Claim billing NPI matches MCS site NPI, Claim billing ZIP matches MCS site ZIP
9 / Claim billing NPI matches MCS site NPI without any ZIP match
10 / Claim billing ZIP matches MCS site ZIP without any NPI match
99 / Active site with no NPI or ZIP match

Claims Exception Overview

Matching Claims

These claims are automatically denied but AlphaMCS will list them in the Claim Exception screen so that staff can enter the correct information so the claim will show up on an RA for the provider to rectify and rebill as necessary.

To match the claim to a patient, provider or site click thebutton identified in the above screenshot in the Claim Header tile.

If the provider is missing, you’ll have a ProviderSearch button, if the patient is missing, you’ll have a PatSearch button. When you’ve put in the missing information, choose a reason from the Reason dropdown and click Update.

Also within this module you will be able to match cliams per site. You can do so by clicking on the Site drop down and chosing the correlated site.

If you’re unable to match a Provider or Patient, you can clear the claim from your queue by checking the Acknowledge checkbox, choosing a reason, then clicking Update.

Claims Exception Scenarios

Scenario 1: A claim is processed and has a patient that can’t be matched on combinations of identifying information (policy #, name, DOB or SSN). The claim will deny for reason #19 Incorrect Member—Patient not enrolled on DOS. It also goes to the exception list with the patient name blank. If the claim isn’t worked and readjudicated by the next check write date, it will show on the RA and 835 as denied.

Scenario 2: A claim is processed and the billing NPI doesn’t match any providers in the system. It goes to the exception list with the provider and site fields blank. The claim will deny for reason #27—Invalid Provider NPI. No information goes out on an RA or 835 since the system doesn’t know which provider to send it to.

Scenario 3: A claim is processed and the billing NPI is just for a single provider, however, that provider has multiple sites that use the same NPIs and zip+4. The system is unable to determine which site the claim is for and it denies for reason #122—Specific site could not be determined. The claim will also go to the exception list with only the site field blank.

Scenario 4: An institutional claim is processed and the billing NPI is shared across multiple providers. The system will then look to see if it can match the submitter ID to a single provider. If it can’t, the claim will go to Claims Exception and deny for #27—Invalid Provider NPI. No information goes out on an RA or 835 since the system doesn’t know which provider to send it to.

For all claims on the exception list:

-after matching patient/provider/site, you must re-adjudicate in Claims Maintenance

-they will remain on this list until they are worked

-under a single claim header, claim lines with the necessary information will adjudicate and those that don’t will go to the exception list. When readjudicated, the system will re-adjudicate the whole claim header.

Claims that don’t go to claims exception:

-pended rates: they deny

-professional claims that have a billing NPI that is shared by multiple providers: a provider is assigned

Tech Notes

PERMISSIONS:

Au_lvl / FCE
Module / Claims
Screen / Claim Exception
Tasks List / Matching

TILES:

TILE / LIST BRINGING STORED PROCEDURE / PASSING PARAMETERS
CLAIM HEADER / By the default it won’t bring any list.only by filter it will bring the list.
asp_sel_claim_exception_list / from_dt,to_dt,clm_num
CLAIM LINES / asp_sel_claim_exception_data / clm_hdr_id
EXCEPTION UPDATE / asp_sel_claim_data / claim_id,claim_type as “H”,ret_type as “N”,user_id

BUTTONS IN CLAIM MAINTENANCE BASE TILE:

BUTTON / DESCRIPTION / STORED PROCEDURE / PASSING PARAMETERS
Refresh / Brings the last searched item / asp_sel_claim_exception_list / from_dt,to_dt,clm_num
Filter / User control page is been called here.Page name :ClaimExceptionSearch
Search / Searching claims by passing the particular values. / asp_sel_claim_exception_list / from_dt,to_dt,clm_num
Update / It can be viewed under view 3 click.User control page is been called here. Page name:CreateClaimHeaders / While saving it calls the stored procedure “asp_iu_claim_exception” / The fields in this screen are filled up by
The stored procedure “asp_sel_claim_exception_data”
Passing the value “clm_num”
Pat search / This brings the separate search control for bringing the Patient #.Page name:Searchcontrol / asp_sel_pat_list_data / ln,fn,dob,ssn,patid,active,
secure_search as “0” for mco and “1” for portal,
insuranceid,mrn.
Prv search / This brings the separate search control for bringing the Provider #.Page name:Slotprovsearch / asp_sel_provider_list_data / Prv_id,stat_id,org_type_id,prv_nm,zip,prv_splty_id,active,usrid