ServiceXG Basics

Disputed cases

Track a member'sdisputed cases. A disputed case can be a disagreement about the amount due on a bill, the amount the insurance company paid on a claim, the nonpayment of a claim, or similar situations.

Enter a disputed case

1. Search for and open the member to update.

2. From the Claims menu select Disputed Cases.

   

   Any field with an asterisk * next to it or a red border around it must be completed before you can continue.

   Disputed Case Info field descriptions

   * indicates a required field

   Field	Description
   Case No.	System generated number for the disputed case.
   Type *	The disputed case type. Each site defines the types depending on their needs, types could include S—Subrogation and W—Workers Compensation.
   Status *	The disputed case status. O—Open C—Closed
   Open Date	Date the case was opened. We recommend this be the accident or injury date of the to assist operators in identifying associated claims. If your system is configured to, when entering the case the current date is entered when tabbing or pressing Enter.
   Closed Date	Date the case was closed.
   Total Billed Amount	The total amount billed for the case.
   Recovered Amt	The amount recovered in the case settlement.
   Operator	Auto-updated ID of the person who created the case.
   Total Paid	Calculated total amount based on the linked claims associated with the case.
   Settlement Amount	The amount agreed upon to settle the case.
   Comment	Additional information associated with the case
   Associated Claims or Disability	Selection option to display the associated claims or disability claims which are reflected in the Total Paid amount.

3. Any existing cases display. To add a new case, click below the tracking table .

   

   Note: The information that you enter into the Disputed Cases table displays as an option in the Linked Disputes for Claim list on the Links workspace.
4. Select the case Type. Type codes are user-defined.

5. Select the Status, either Open or Closed.

   Note: Default disputed case types and status come pre-loaded with the software, but can be added, edited, or deleted by your administrator. Contact your administrator for more information.
6. Select the date you opened the case at Open Date. Click and select a date or enter a date in MM/DD/YYYY format.
   • When you close the case, update the Closed Date.
7. Enter the Recovered Amount.
   • Your User ID automatically displays as the Operator.
8. The Total Paid amount updates based on all claims that are linked to the disputed case.
9. Enter a Settlement Amount if this is part of your office process and you have settled the case.
10. Enter any comments associated with the case in the Comment box.
11. Click and then .

Link associated claims to a disputed case

1. From the Case Info subtab, select Associated Claims, then click Link Claim to display a window with claims (if any are available) to select from.

   

2. Use the check boxes to select the claim or claims to link and click OK.
3. The claim you selected displays in the table.

Update a disputed case

1. Click the case table row to update. The fields below the table display the information for that case.
2. Update the necessary information (Closed Date, Settlement Amount, and Comments, etc.).
3. Click and then .

View disputed case disability details

From the Case Info subtab, select Disability. A read-only table of disability transactions related to the case displays.

Filter disputed case criteria for claims

Set up criteria for claims (associated to a disputed case) to pend P26 (disputed). If a disputed case is open for a member/dependent, only claims that match the criteria will pend P26 (disputed) and all other claims will process as normal, whether they be released or pended under another code. Set this criteria up to increase the auto adjudication rate for claims that are unrelated to the disputed case.

1. Click the case table row to update. The fields below the table display the information for that case.
2. Click the Filter Criteria tab.

3. Click .

   

   Filter Criteria subtab field descriptions

   * indicates a required field

   Field	Description
   From Date*	The first day of the effective date range. This date is used to validate against the claim lines' From Dates.
   Through Date*	The last day of the effective date range.
   Plan Type	If a disputed case claim matches this plan type A plan type identifies a type of benefit plan, such as HMO or Indemnity., the claim pends P26. If not, the claim is ignored. If this field is left blank, the data isn't taken into consideration when filtering.
   Billing Provider ID	If a disputed case claim matches this billing provider The billing provider is the individual or organization that is billing the fund for services rendered by a specific service provider. ID, the claim pends P26. If not, the claim is ignored. If this field is left blank, the data isn't taken into consideration when filtering.
   Diagnosis Code	If a disputed case claim matches this diagnosis code, the claim pends P26. If not, the claim is ignored. If this field is left blank, the data isn't taken into consideration when filtering.
   Procedure Code	If a disputed case claim matches this procedure code A claim procedure code that identifies a specific service performed by a service provider., the claim pends P26. If not, the claim is ignored. If this field is left blank, the data isn't taken into consideration when filtering.
   Benefit Code	If a disputed case claim matches this benefit code Identifies the service type provided and determines the payment within the schedule. (codes differ per location), the claim pends P26. If not, the claim is ignored. If this field is left blank, the data isn't taken into consideration when filtering.

4. Enter the criteria's effective date range. Enter the first day of the date range for From Date and the last day for Through Date.

5. Enter the criteria. This can be any combination of Plan Type, Billing Provider ID, Diagnosis Code, Procedure Code, and Benefit Code.

   1. Click the field to add criteria. The bottom table changes to the field type you've clicked.

      

   2. Click .
   3. Click the new empty row. Type the type, ID, or code. Depending on the criteria type, you might be able to search for the type/ID/code or select from a list. For example, you can select a Plan Type from a dropdown list, as shown above.
   4. If you want to add more than one type/ID/code, click again.
6. Once you've added the criteria, click to update the disputed case.
7. Click to save.

Create a disputed case report

1. To get a claim's history report for the member's disputed cases.
   • Any linked disability occurrence detail related to the disputed case, shows at the end of the report.
   • The case report will include any disability or health claims for a member or dependent.
2. Click .
3. Retrieve the report from the print queue. See Print queue—Retrieve a print job.

SEE ALSO