August 2004 Newsletter
Standalone Insider
Balancing Electronic Claims
by
, HARP Technical Support Manager, Partner
Reviewing all these reports ensures HARP Standalone clients that their claims are being received and processed:
- Approval Report - number of claims submitted and rejected by insurance carrier
- Unresolved (Summary & Detail) Electronic Claims Report - number of claims that may not have been processed
- Report of Insurance Claims (RPTINS) - number of electronic claims created in HARP
Just as importantly, balance these reports against each other to keep claims from slipping through the cracks!
Report of Insurance Claims
HARP insurance processing generates a Report of Insurance Claims. This report lists and subtotals claims by carrier and whether the claim is rejected, electronic (SII FILE) or hardcopy (HCFA1500):
INSURANCE COMPANY - AETNA SELECT CHOICE(11)
NAME ACCT NUMBER PHYS TYPE AMOUNT ORIGIN TICKET CLAIM INFO
NAME, PATIENT 982783007-01 LD SII FILE 63.00 FB 488762
NAME, PATIENT2 968389820-01 BR HCFA1500 49.36 SB 495723
NAME, PATIENT3 990075475-01 PH HCFA1500 14.24 DA 484098
TOTAL FOR INSCO : 3 CLAIM(S) 126.60 DOLLARS
2 HARD COPY 63.60 DOLLARS
1 ELECTRONIC 63.00 DOLLARS
0 REJECTED 0.00 DOLLARS |
If the HARP insurance process determines a claim to be invalid, it will reject the claim and list the reason under CLAIM INFO:
INSURANCE COMPANY - AETNA US HEALTHCARE(10)
NAME ACCT NUMBER PHYS TYPE AMOUNT ORIGIN TICKET CLAIM INFO
NAME, PATIENT NEWSTMNT-01 E2 HCFA1500 187.20 AB 448
NAME, PATIENT2 NEWSTMNT-01 M3 **REJECTED 0.00 AB 444 CHARGED IN ERROR
TOTAL FOR INSCO : 1 CLAIM(S) 187.20 DOLLARS
1 HARD COPY 187.20 DOLLARS
0 ELECTRONIC 0.00 DOLLARS
1 REJECTED 0.00 DOLLARS |
The rejected ticket will also go to the CLMERR work list and post a message on the ticket indicating it is from the Report of Insurance (RPTINS):
2 05/03/04 RPTINS-CHARGED IN ERROR # SYS |
At the end of the Report of Insurance are the Insurance Company Totals that lists, by insurance carrier and a grand total, the totals of hardcopy and electronic claims and the dollar amounts billed. It also gives the total number of Rejected claims from HARP:
INSURANCE COMPANY TOTALS
|------- HARD COPY ----------| |------- ELECTRONIC ---------|
INSURANCE CO NAME CODE HCFA UB92 TOTAL TOTAL SII UB92 TOTAL TOTAL TOTAL TOTAL
COUNT COUNT COUNT $ AMT COUNT COUNT COUNT $ AMT COUNT $ AMT
AETNA US HEALTHCARE 10 1 0 1 187.20 0 0 0 0.00 1 187.20
ANTHEM BC/BS 03 4 0 4 232.40 0 0 0 0.00 4 232.40
CATERPILLAR 713 0 7 7 674.66 0 0 0 0.00 7 674.66
MEDICARE-OHIO/WEST VA 02 3 0 3 262.00 0 0 0 0.00 3 262.00
_____ _____ _____ _________ _____ _____ _____ _________ _____ _________
TOTALS 8 7 15 1356.26 0 0 0 0.00 15 1356.26
REJECTED 1 0.00 DOLLARS |
The electronic insurance file is then transmitted to Quadax via HarpComm. HarpComm not only transmits electronic claims to Quadax, but also retrieves remittance files, Approval reports, Payor Front End reports, and Quick claims status. Within the Quick claims status are Quick rejected claims and unresolved claims along with accepted claims. Accepted claims, rejected claims, and unresolved claims post a message on the ticket.
Rejected: 05/05/04 QUICK ERROR: 23L01,HIC NUMBER INV/MISS # SYS
Accepted: 02/16/04 QUICK MESSAGE: CLAIM ACCEPTED # SYS
Unresolved: 12/24/03 UNRESOLVED CLAIM: 266076 # SYS |
Unresolved Electronic Claims Report
Rejected claims are placed in the CLMERR work list to be reviewed and worked. Unresolved claims, claims created in HARP but not processed through Quick, go to the Unresolved Summary (and Detail) Electronic Claims Report. Quick is the process in which electronic claims are edited and then processed to the insurance carriers.
If all claims were processed, the Summary report will indicate that no claims were selected. This is good:
UNRESOLVED DETAIL ELECTRONIC CLAIMS REPORT
ATTENTION: TECHNICAL SUPPORT DEPARTMENT
ORIGIN STATUS
ACCT# NAME TICKET CLAIM# BILL DT BILL AMT OF CLM OF CLM
PROCESS DATE:
INSURANCE: -
*** NO CLAIMS SELECTED *** |
If claims were not processed, the Summary report will indicate the processing date and list the total number of claims by carrier that was not processed. This is not good:
UNRESOLVED SUMMARY ELECTRONIC CLAIMS REPORT
TOTAL
INS CODE INS NAME CLAIMS
PROCESS DATE: 04/23/04
01 MEDICAID-OHIO 29
02 MEDICARE-OHIO/WEST VIRGINIA 40
04 MEDICAL MUTUAL OF OHIO 7
1000 AETNA NON-HMO 1
2556 APEX BENEFIT SERVICES 2
73 ACORDIA NATIONAL 1
TOTAL CLAIMS FOR 04/23/04 : 80 |
When the report does list claims for any carrier, contact your Technical Support Consultant immediately. If the Total Claims for the date (MM/DD/YY) match the number of electronic claims listing on the Report of Insurance for the Process Date indicated, then the entire file was not processed. Occasionally, it may list claims for a specific carrier. There can be a number of reasons that the claims may not have been processed, but whatever the reason, it is usually corrected the same day it is reported. Once the claims have been processed, they will no longer appear on the report the next time the report is generated.
It is very important to review this report every time HarpComm submits claims. The Unresolved report is not generated if HarpComm is being run only to retrieve files such as remittances.
Example:
- Claims are transferred on Monday.
- HarpComm runs on Tuesday to pull back Quick rejects, remit files, and reports.
- The Unresolved report is created.
- If HarpComm is run again on Wednesday to check for any new remit files, Unresolved reports will not be generated.
Balancing Reports
Approval
+ Unresolved
= Electronic |
Now that we know the reports that can be used, let us put them together to balance electronic insurance claims:
- Approval Report - number of claims submitted and rejected by insurance carrier
- Unresolved Summary Electronic Claim Report - number of claims that may not have been processed
- Report of Insurance - number of electronic claims created in HARP
The number of claims submitted and rejected from the Approval list added together with any claims that may appear on the Unresolved Claim report should balance to the number of electronic claims on the Report of Insurance.
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