Action option

From the Action option, you can do the following:

Calculate (F7) a claim

The Calculate option allows you to calculate claim information. It is the same as using F7. See How claims are calculated.

Pend a claim

The pend A discount or set contribution amount that is credited to the employer reducing the contribution obligation. option allows you to pend a claim. When you choose this option, the Pend Reason window displays.

To enter a pend reason code, use the list to select the necessary code and then click OK. The Pend Reason code displays in the table.
To delete a pend reason code, click Remove, use the list to select the necessary code to remove, and then click OK.

Deny a claim

The Deny option allows you to deny a claim. When you choose this option, the Create Denial dialog displays.

To deny a claim, enter the claim lines to deny. You can deny an entire claim by selecting all lines or you can select a portion of the claim.
Enter a valid ineligible code as the denial reason.
Click OK. The Ineligible Code on the Lines workspace updates with the Ineligible Code that you entered as well as the corresponding Ineligible Amount.

Remove a claim denial

The Remove Denial option allows you to "undo" the denial of a claim. When you choose this option, the Remove Denial dialog displays.

To remove a claim denial, enter the claim lines containing the denial code to remove.
Enter the ineligible code to remove from the claim lines.

Hint: If you don't know the correct code, use the shortcut keys Ctrl + L to access the code look-up.
Click OK. The Lines workspace Ineligible Code that you selected is removed from the Lines workspace.

Add eligibility and pricing information

The Add Eligibility and Pricing Information option allows you to determine certain eligibility coverage information that is used to process the claim correctly.

Eligiblity and Pricing Field Descriptions

Field	Description
Apply PPO selection to all lines.	Check box that applies the selected PPO and pricing information to all claim lines.
Apply referral selection to subsequent lines	Check box that applies the selected service code to future claims lines.
PPO and Pricing Information	`PPO`—Code for Preferred Provider Organization (PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount.). `From Date`—Beginning date for pricing information. `Thru Date`—End date for pricing information. `Schedules`—User-defined parameters that automate the eligibility calculation based on individual plan rules. `Prov RV`—Provider Relative Value (RV). These units assess the procedure complexity and might impact pricing. `Prov UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills.`—Provider Usual and Customary Rate (USR) procedure source code for the PPO. `Pre-price`—Associated pre-pricing code. `Source`—Service Provider or Billing Provider.
Referral for Procedure <procedure code> on <date of procedure>	`Referral#`—Number of referral `Type`—User-defined `Status`—User-defined codes that identify whether a participant is eligible and how they obtained or lost eligibility. The first portion of the code indicates whether the individual is eligible (Y for eligible; N for ineligible). `From Date`—Beginning date of referral `Thru Date`—End date of referral `To Service Provider`—Service Provider on the referral `Approval Sts`—User-defined Approval code.
Schedule	A payment criteria summary including benefit codes, co-insurance percentages, accumulators, and pricing guidelines that automates the claims benefit determination.
Service Code for Referral	`Service Code`—The service code for the service covered by the referral. This could be a user-defined service code or a procedure code. `Service Code Description`—Description of the service code. `Used Qty`—Number of approved visits used. `Approved Qty`—Number of approved visits or the approved dollar amount for the referral. `Quantity Type`— Indicates if the quantity is a dollar amount or number of visits. `D`—Dollars `Q`—Quantity (number of visits)
Subgroup and Plan	`Subgroup`—A breakdown or grouping of individuals within a fund A plan's asset pool held in trust for the benefit of union members and their families. The fund is the foundation of the basys system. Fund type examples include, welfare, pension, annuity and political action.. `From Date`—Beginning date for individual's membership in the subgroup/plan. `Thru Date`—Ending date for individual's membership in the subgroup/plan. `Status`—User-defined codes that identify whether a participant is eligible and how they obtained or lost eligibility. The first portion of the code indicates whether the individual is eligible (Y for eligible. N for ineligible.) `Coverage`—The coverage code identifies who is covered by a benefit plan type, for example, individual or family. `Benefit Plan`—identifies the actual benefits a member or dependent receives as the result of association with a subgroup. `Plan Type`—The claim benefit plan type (e.g. medical, dental, or vision). The first claim line determines the claim plan type.

All five fields display when accessing this option from the Star menu.When you're not using the Star menu, this window might display automatically as part of an edit, particularly a BCode edit. If it is part of an edit, only the applicable edit fields display.

The fields on the Eligibility and Pricing window are independent of each other. The subgroup A way to categorize group members into a certain set for benefit plans (e.g. active and retired employees). Subgroup distinctions are only used in Claims, COBRA and Eligibility. and Plan, and schedule Defines parameters for Apps, contracts, status', pay, benefits, rules, etc.. fields display together, and the Referral for Procedure field and possibly the Service Code for Referral field might display together depending upon the situation.

Select the appropriate information from the options. Refer to the Eligibility and Pricing field descriptions above.

Enter a manual discount

The Manual Discount option allows you to enter a discount arrangement with a provider. When you choose this option, the Manual Discount dialog displays.

Enter the appropriate claim line.
Enter the discount amount.
Select the type of discount.
Click OK to apply the discount to the claim.

Delete a claim

When you choose the delete a claim option, a confirmation message displays.

Click Yes to delete the claim or No to cancel.

Add a claim reduction

According to federal regulations, providers that don't preauthorize benefits when the fund requires authorization are subject to provider sanction. Applying the sanction involves the reduction of the plan allowance by either a percentage or flat dollar amount. The sanction reduction is applied to each line and the provider is considered responsible.

When you choose the Claim Reduction option, the Claim Reduction dialog displays. From here, you can choose either a flat amount or a percentage reduction at the line or claim level. You must have the appropriate permissions to access this option.

In the Claim Line box, enter the Line Number for the claim reduction, leave it blank or enter 0 to take the reduction on the entire claim.
In the Reduction Basis, select either B (Billed) or A (Allowed). The reduction will be taken off this field.
In the Ineligible Code box, enter the valid Ineligible Code for the reduction.
Select the Reduction Type. Choose either F (Flat) or P (Percentage).
In the Reduction Amount box, type the flat or percentage dollar amount.
Click OK.
The Ineligible Code and Amount displays on the Lines workspace and the recalculated values display on the Detail viewport.

Add or update claim prepaids

The Claim Prepaids option allows you to add, update, or delete Member, Medicare, and Other (insurance carrier) prepaid information if you have the appropriate authorization.

Click OK to update the information on the Lines workspace and the Prepaids viewport.

Distribute benefits across claim lines

The Distribute Claim COB A provision for determining benefits when a member has more than one benefit plan. option allows you to enter and distribute claim-level Other insurance Paid and Allowed Amounts across the claim lines. It also removes the discount information from the Ineligible Code and Ineligible Amount on the Lines workspace and removes the Ineligible Code, Ineligible Amount, and Considered Amounts from the pend P24—Prepricing Information.

There must be a PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. on the claim and that PPO must be the retained PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. setup in your system to remove these discounts. If the PPO isn't set to be retained, the discounts are removed from the Ineligible Code, Ineligible Amount, and Considered Amounts in pend P24 when the claim is calculated, but the Ineligible Code and Ineligible Amount on the Lines workspace won't be removed.

Enter the Allowed and Prepaid Other Insurance amounts.
The Difference updates automatically.
Click Distribute COB.

Note: You must have the appropriate permissions to use this option.

Change the claim type

The Change Claim Type allows you to change the type of an in-progress claim, for example, from Professional to Dental.

When you choose the Change Claim Type (CCT) option, the Change Claim Type dialog displays.

Select the new claim type.
Click OK.
The claim type you selected is added to your claim and the claim recalculates and you may need to review the claim.

Close a claim (Ctrl + W)

When you choose the Close a claim option, if you have saved your changes the claim closes.

If you have unsaved changes, a confirmation message displays.
Click Save to save your changes and exit, Don't Save to exit without saving your changes, or Cancel to remain in the record without saving.