Claimant Audit

Use the Claimant Audit screen to specify the criteria used to select claims of individuals or all family members for audit. You can create more than one audit criteria with overlapping from and thru dates if needed.

Access Claimant Audit

There are a few ways to access Claimant Audit from a member, dependent, or claim:

Search for and open a member or dependent.
Select Claims, and then select Claimant Audit.

Search for and open a member or dependent.
Select Claims, and then select Third Party.

From Audit Claimant, select View Details.

Search for and open a claim.
Select Patient, and then select Claimant Audit.

The Claimant Audit screen displays the audit criteria.

Note: You might not have access to view or update information on this screen. Contact your administrator for access.

Claimant Audit Field Descriptions

Field	Description
From Date*	The from date for the audit criteria. This prompt is required when adding or updating criteria (this prompt considers the date of service on each claim line).
Through Date*	The through date for the audit criteria. This prompt is required when adding or updating criteria (this prompt considers the date of service on each claim line).
Audit Type*	Determines if claims for this member or dependent will be selected for automatic audit. (See Process Overview, Held Claims.) This prompt is required when adding or updating criteria: `Y—Audit Claimant` Claims for this member or dependent will be audited. `N—No Audit` or `Blank`—Claims for this member or dependent won’t be audited. `F-Audit Family`—Claims for the member's entire family will be audited. You can only select this audit type for the member.
Comment	Enter an optional comment about the audit criteria. You can enter up to 36 characters.
Inactive	Select the check box if the audit criteria is inactive.
Modified By	The name of the operator who last modified the criteria.
Modified When	The date and time the operator last modified the criteria.
Criteria	Includes a check mark to indicate the criteria exists.
Fund	The 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. ID associated with the contribution or payment.
Group	Group for which the claim was processed.
Plan Type	The claim benefit plan type (e.g. medical, dental, or vision). The first claim line determines the claim plan type.
Operator	User ID of the individual who entered the information.
Subgroup	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. for which the name was processed.
Plan	Plan for which the claim was processed.
PPO	Preferred Provider Organization (PPO) code used in paying the claim.
Schedule	The schedule for the criteria.
Coverage	The coverage code identifies who is covered by a benefit plan type, for example, individual or family.
Diagnosis	The ICD diagnosis code for the claim.
Procedure	A code that identifies a specific service performed by a service provider. Note: There is a standard set of Procedure codes but your office might use other codes such as revenue or internal codes for your Procedure codes.
Benefit Code	The benefit code representing a benefit or service covered in the Summary Plan Description document (e.g. eye exam, emergency outpatient care or an office medical visit).
Billing Provider	The individual or organization that issued the bill for the services listed on the claim.
Service Provider	The service provider's ID number.
Billing NPI	The service provider’s National Provider Identifier (NPI). This is a 10-digit ID assigned to the provider by the National Plan and Provider Enumeration System (NPPES). It is possible for service providers under one billing provider to have the same NPI. For example, groups or organizations with multiple subparts could share the same NPI.
Service NPI	A unique identifier issued by the National Plan and Provider Enumeration System (NPPES) to all health care service providers who want to send or receive HIPAA transactions.

Add audit criteria

From the Claimant Audit Info table, select to add audit criteria.
Select the From Date, Through Date, and Audit Type.
Enter an optional Comment.
If the criteria is inactive, select the Inactive check box.

Choose the criteria used to select claims of individuals or all family members for audit as needed. If you don't enter any criteria, all claims will be audited. At the Criteria table, click Fund in the table in the upper table.

Select to specify a fund to include in the lower table. Choose a fund from the dropdown list.

Click Include to include the fund or click Exclude to exclude it.
Select another criteria to add from the table, for example, Group. The Fund field updates.

Complete the above steps to select a Group, Plan Type, Operator, Subgroup, Plan, PPO, Schedule, and Coverage.
For the Diagnosis, Procedure, Service Provider, Billing NPI, and Service NPI fields, click a row in the upper table and enter a value in the lower table.

For the Benefit Code and Billing Provider fields, click in the row in the upper table, and search for a value in the lower table.

If you need to delete any of the values, select the criteria from the row and press .
After creating the audit criteria, click .
Click to save.

Update audit criteria

From the Claimant Audit Info table, select the audit criteria to update.
Edit any of the information as necessary.
Click .
Click to save.

Delete audit criteria

From the Claimant Audit Info table, select the audit criteria to delete.
Click to delete the criteria.
Click to save.