Categorization of Adjudications

Version 14.8
Path: Smart Toolbar > Billing button > Adjudications tab

Overview

The Adjudications tab displays all pending claim adjudications that have been processed through ERA (835) files. This tab is split into two screens:

  • Matched Tab: This grid shows adjudications with ERA transaction details linked by ERA transaction OP claim numbers. Once an adjudication is approved for posting to a patient account, it will be removed from this screen. When adjudications are initially processed into OP, they are categorized into one of the following match statuses (defined as an action to take):
  1. Unmatched - Adjudication will not be processed, as OP cannot clearly identify the transaction being adjudicated. You will need to match the adjudication to a pending claim (by entering the correct transaction number on the adjudication line), then switch the match status to Matched prior to approving the adjudication. This will happen if a payer substitutes an alternate CPT code from the one originally submitted by your office or when your office changes a CPT code from the original code submitted.
  2. Matched - Adjudication will be processed/posted as outlined on the screen.
  3. Review - Adjudication will not be processed because OP or a user has flagged this adjudication for further review, based on the adjustment code reason. The user will need to further research or take another action based on the claim denial. Once an action has been taken, the user can choose to switch the match status of this adjudication to Discard, so that there will be no action taken on the existing adjudication. Or, the user can leave the adjudication in Review status, pending the receipt of a reprocessed adjudication.
  4. Appeal - Adjudication will not be processed because a user has flagged this adjudication for appeal documentation to the specified payer. Once an appeal has been generated, the user can choose to switch the match status of this adjudication to Discard, so that there will be no action taken on the existing adjudication. Or, the user can leave the adjudication in Appeal status, pending the receipt of a reprocessed adjudication.
  5. Paid - Adjudication will be deleted from the table (with NO action taken) as OP has determined that there is no insurance balance due on this claim. Note: Most often, these adjudications are adjustments only, where claims are being denied for duplicate submission. However, it is important to take note of whether there is an actual payment from the payer on the adjudication line. Either this payment was manually posted (hence the claim appears paid), or the balance was previously transferred to the patient and it may or may not have been paid by the patient. In this case, you will need to transfer the balance back to the insurance and change the match status to Matched, to ensure that the adjudication is properly processed.
  6. Repriced - Adjudication will not be processed because a user has flagged this adjudication as pending repricing/reprocessing from the payer. Once an action has been taken, the user can choose to switch the match status of this adjudication to Discard, so that there will be no action taken on the existing adjudication. Or, the user can leave the adjudication in repriced status, pending receipt of a reprocessed adjudication.
  7. Discard - Adjudication will be deleted from the table (with NO action taken), because a user has flagged this adjudication for this purpose. Most often, this match status is selected when an adjudication has been manually posted to a patient's account. In addition, a user can change a match status from Review, Appeal or Repriced to Discard once the user has taken an action (called payer for reprocessing of claim, mailed appeal letter, etc). The adjudication can be discarded (with NO action taken) if the user has already identified that the adjudication, as it stands, should not be processed into OP. In this situation, it would benefit the user to clearly document in the Claim Note field any action taken (in terms of reprocessing, appeal, etc.) for future reference.
  • Unmatched Tab: This grid shows adjudications with ERA transaction details that could not be unambiguously matched by OP to a claim. These adjudications will need to be manually matched against existing claims in order to be moved to the Matched tab for review and posting approval. On the bottom portion of this screen, OP will list possible matches based on patient name, service date, and CPT code. It will be up to you to select the correct match. If, however, there is no existing match in OP (possibly because the claim was billed in a different software), the adjudication can be deleted from this screen.

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