How to Manage Remits on Hold Status

How to Manage Remits on Hold status

How do I manage system delivered Hold?

We system deliver a number standard reasons to Hold claims for manual review. In the same way, when you are manually posting, you may decide to not post some adjudication from the payer, we hold these claims for you to make a decision what to do. Please see your client manager for how to add or take away rules delivered based on your needs.

Charge - Allowed - Adjustments does not Equal $0

Definition: One or more of the CPTs do not have an allowed amount or the allowed amount does not reflect the adjustments made by this insurance. This encounter is on 'HOLD" for the user to review.

Question to ask: Do we accept this denial and write this amount off OR do we plan to contact the insurance company to reconsider

Action: Use the 'Claims Action' Drop-down to:

1. 'Post as Note/Leave Balance' - then change the Remit Status/worklist to 'DW-Denial Worklist' to work later

2. Accept the write-off by 'Posting as Remitted.'

Procedure in ERA does not Exist on Encounter

Definition: One or more line items do not match exactly what is on the encounter. This is usually a result of an addition of a modifier or some other change that was made after the encounter was sent to the payer. At times the payer will take a two unit bilateral line and separate it to pay on one line. In those sorts of instances- use manual post.

Action: The line needs to be 'mapped'. Use the Line drop down > choose the correct line number > post a usual

Payments/Adjustments will Create Credit

Definition: If the credit is caused by a previously posted adjustment

Action: In our example, a previous ERA came in with OA133 that was posted in full. This caused the newest remit to go on hold.

In this example we needed to 'undo' a previously posted adjustment of OA133.

Click [Post Expert]

Transaction code of the adjustment we want to undo, in this case OA133
The equal but opposite amount > Tab
[Save] the popup and [Save] the post expert page

Encounter is Reversed

The Remit has gone on 'Hold' because the original encounter has been reversed, therefore the system cannot automatically post this receipt. You will need to manually post this receipt.

If the original encounter was reversed for modification there is a new encounter number in the system:

Click on the encounter number to view the 'Actions' section of the original, write down this number
Go back to the ERA Remit
Click on the Receipt number
Use [Post] or [Post Expert Mode] to post the money to the new encounter

Keep in mind the insurance company may do a takeback in the future so we recommend keeping good notes on the new encounter and/or add the item to a worklist.

Remit is on Hold - Transfer to Non-Existent Secondary/Tertiary

The Remit is on Hold because we do not have a secondary or tertiary on file and the Primary Insurance has forwarded the claim. At times this means the patient didn't give us their secondary or tertiary.

We may not want to bill the patient if an insurance is present.

1. Click the 'Insurance Management' hyperlink

2. Click to Edit the existing Insurance Profile, in our screenshot we click the word 'Default'

3. Click to 'Add New' or From Existing

4. In our example we do not know the policy number so we key in the word 'Pending' and add a note as to where we got this information from

5. Save the new policy then Save the profile.

6. Use the back button to return to the Remit page, use the select drop down to 'Post as Remitted' > Save the remit

At other times it may mean there is a HSA/HFA. In those case we may want to post as remitted.

Payer paid claim as Primary when payer is Secondary in the Insurance Profile

Note the message in green 'Processed as Primary' - in this Example the ERA was received from United Health Care, which is the secondary in the Insurance Profile and therefore has gone on Hold for 'Insurance on Remit does not Exist on Profile'

Use [Manual Post] > In the Dropdown 'Change Responsibility' > Post