ServiceXG Basics

Adjust claims associated with a disputed case

When money is recovered from a (claims or disability) disputed case, you must credit it to the appropriate fund and adjust the disputed claim.

Disputed case claims adjustment process

1. Enter the disputed case and link all associated claims (see Adjust claims associated with a disputed case).
   • Disputed case types need to be setup prior to using disputed cases.
2. Reverse claims when money is recovered (see below).
3. Update the overpayment record to reflect the recovered money (see Overpayment refund).
4. Enter a historical claim if necessary.

Reverse the claim

1. Access Administration Processes > Claims Adjustments > Claim Reversal/Void to open a classic session and reverse the claim.

   

2. Enter the Refnos linked to the case, up to the amount recovered or just beyond.
3. Enter D (dispute) at Void Reg (Register)as this is a disputed case.
4. Enter N (no reissue) at Reissue since you don't want to reprocess the claim.

5. Enter an adjustment Reason Code that will show in the Adjustment viewport.

   A code that identifies the adjustment reason. These codes can be site specific.

   • AD—admission choice error
   • BA—billed amount error
   • BC—benefit code error
   • BP—billing provider choice error
   • BQ—billed quantity error
   • CB—COB/prepaid entry error
   • CD—check damaged
   • CL—claimant choice error
   • D—diagnosis error
   • DC—disputed case choice error
   • DP—duplicate claim
   • DS—dates of service error
   • IL—illness choice error
   • PA—provider address error
   • PO—payment override error
   • PP—PPO choice/pre-priced entry error
   • PR—procedure error
   • RD—received date error
   • RF—referral choice error
   • RS—referral service choice error

6. Enter C to continue. No claims are reissued and a claim entry session isn't launched. The original claim refno displays at the bottom of the screen.

   Hint: Take note of the refnos that display for any necessary additional processing.
7. Press Enter and the claim reverses. The reversed claim refno displays.
   • All accumulators are calculated and automatically adjusted.
   • Any informational or error messages display.

8. Press Enter again to close the screen.

   Important! If you accidentally void the claim, void it again or reverse it. To do this, enter the adjusted reference # (e.g. A00041 in the example below) in Reverse/Void. Void the reversed claim in the same accounting month to return the original claim to its original status or void again if you're in a new accounting month.
9. Next:

   1. Enter an Overpayment refund for the recovered amount using the ID number you created for disputed cases (see Overpayment refund).

      Note: Your system can be configured to automatically reduce disability transactions by overpayment amounts, or prompt the operator to recover an overpayment amount, or have no overpayment reduction. Contact your Bridgeway representative to set or change SAC (System Administration Control) settings. Don't change SACs without first consulting Bridgeway as changing them can affect other functions and global system settings.
   • You will need to create a provider (disputed) to process the recovered payment so that received monies will reflect in the registers (see Add billing and service providers). This provider could be the individual attorney's tax id number or a single provider number created for of disputed case recoveries.
   • When you access the overpayment screen, enter P for provider and the created ID number. Enter the fund where the money will be credited. Remember that the reversed amount isn't in the overpayment so the overpayment amount will show as a positive amount.
   • Add the received payment with an action date when the payment was received. If you don't want the recovered payment to display as an overpayment refund, add the negative amount of the received payment to bring the balance to zero and use an action date of 1/1/80.
   2. Enter and process a historical claim for the difference, since you'll rarely receive a check exactly equal to the amount paid (see the Enter a historical claim topic).
      • If you don't recover the full paid amount, the last reversed claim will only be partially recovered. Enter a historical claim for the overlap amount to ensure the patient's accumulators reflect the appropriate amounts. Remember the historical claim process doesn’t generate a check.

   3. Link associated claims to a disputed case.

SEE ALSO