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We are currently updating the OP Help Center content for the release of OP 20. OP 20 (official version 20.0.x) is the certified, 2015 Edition, version of the Office Practicum software. This is displayed in your software (Help tab > About) and in the Help Center tab labeled Version 20.0. We appreciate your patience as we continue to update all of our content.

Categorization of Adjudications

Version 14.19
Path: Billing tab > Billing Center button > Adjudications tab

Overview

The Adjudications tab of the Billing Center displays all pending claim adjudications that have been processed through ERA (835) files but have not yet been posted to patient claims. The Adjudications tab is split into two tabs, Matched and Unmatched. When Office Practicum automatically processes ERAs, it first looks to see if the remittance matches a claim in the system. A line item is added to the Matched tab if its Patient ID, Service Date and CPT code match an existing claim. Otherwise, the item is moved to the Unmatched tab, where it can be matched manually. An item might be unmatched if you recently started using Office Practicum and the claim was submitted using your old software, so Office Practicum is not familiar with the claim format.

Matched Tab 

The Matched tab lists adjudications with ERA transaction details by ERA payment and OP claim number. After the Match Status (options listed below) is selected or reviewed, the transaction must also be approved for posting. Once the transaction is approved, the actions based on the Match Status are taken and the claim adjudication is removed from this list. When adjudications are initially processed into OP, they are categorized into one of the following match statuses (defined as an action to take):

  • Unmatched: OP cannot clearly identify the transaction being adjudicated. You 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 may occur 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.
  • Matched: Once approved, the adjudication is posted as is. This means that the the adjustments, payment, and patient responsibility is posted to the patient's chart for the claim line.
  • Review: The adjudication is not processed because OP or a user has flagged this adjudication for further review, based on the adjustment code reason. The user needs 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 is no action taken on the existing adjudication. 
  • Appeal: The adjudication is not 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 is no action taken on the existing adjudication. 
  • Denied: Indicates the adjudication has been denied by the insurance. Transactions marked Denied have to be manually approved as Discard or Matched depending upon the intention of the user. It is recommended that claim notes be made for any claims with a Denied Match status to easily follow up on the claim or indicate a claim correction must be made.
  • Paid: The adjudication is deleted from the table with no action taken as OP has determined that there is no insurance balance due on this claim. 
  • Repriced: The adjudication is not 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 is no action taken on the existing adjudication. 
  • Discard: The adjudication is deleted from the table with no action taken. Meaning, the payment, adjustment, and/or patient responsibility is not posted to the patient chart for the claim. A user can change a match status from Review, Appeal or Repriced to Discard once the user has taken an action.This occurs if the user has already identified that the adjudication, as it stands, should not be processed into OP.

Unmatched Tab 

The Unmatched tab lists adjudications with ERA transaction details that could not be matched to a claim. These adjudications need to be manually matched against existing claims in order to be moved to the Matched tab for review and posting approval. In the bottom section of the window, OP lists possible matches based on patient name, service date, and CPT code. It is up to the user 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 tab.

Version 14.10
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 is 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):
  • Unmatched: Adjudication is not be processed since the OP software cannot clearly identify the transaction being adjudicated. You 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 may occur 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.
  • Matched: Once approved, the adjudication with a Matched status is posted as is. This means that the OP software posts all adjustments and payments for the specified claim line.
  • Review: Adjudication is not processed because OP or a user has flagged this adjudication for further review, based on the adjustment code reason. The user needs 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 is no action taken on the existing adjudication. 
  • Appeal: Adjudication is not 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 is no action taken on the existing adjudication. 
  • Denied: Indicates the adjudication has been denied by the insurance. Transactions marked Denied have to be manually approved as Discard or Matched depending upon the intention of the user. It is recommended that claim notes be made for any claims with a Denied Match status to easily follow up on the claim or initiate a claim correction.
  • Paid: Adjudication is deleted from the table with no action taken as OP has determined that there is no insurance balance due on this claim. 
  • Repriced: Adjudication is 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 is no action taken on the existing adjudication. 
  • Discard: Adjudication is deleted from the table with no action taken. A user can change a match status from Review, Appeal or Repriced to Discard once the user has taken an action. This occurs if the user has already identified that the adjudication, as it stands, should not be processed into OP.
  • Unmatched tab: This grid shows adjudications with ERA transaction details that could not be unambiguously matched by OP to a claim. These adjudications 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 lists possible matches based on patient name, service date, and CPT code. It is 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.

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 is 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 is not processed, as OP cannot clearly identify the transaction being adjudicated. You 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 happens 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 is processed/posted as outlined on the screen.
  3. Review - Adjudication is not be processed because OP or a user has flagged this adjudication for further review, based on the adjustment code reason. The user needs 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 is 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 is not 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 is 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 is 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 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 is not 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 is 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 is not 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  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 lists possible matches based on patient name, service date, and CPT code. It is 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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