Default Adjudication Match Status

Version 14.9
Path: Utilities Menu > Manage Codes > HIPPA Codes (Keyboard Shortcut keys: [Alt][U][C][H])

Overview

For a listing of the ERA Adjustment Codes that have been reclassified as Denied with the 14.9 release, click here.

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.

If the characteristics of an item match, Office Practicum next determines the match status. Any line item that is matched, and whose numbers match perfectly (i.e., the full charge amount is accounted for, you received the amount of money you expected to receive, the patient paid the correct amount at time of service, and there is otherwise nothing unusual about the claim) is qualified for auto-approval. However, line items with payer-assigned adjustments require further review before simply accepting the payment and adjustment amounts. You would not want to accept a non-paid or reduced payment if the denial or reduction was based on a reason that may or may not be valid, or is based on a faulty claim submission.

To ensure that the auto-approval feature works as you intend, you should review the pre-assigned ERA Auto-Match values and adjust them (if necessary) based on your practice policies. It is recommended that your office view this list and confirm that the match settings are appropriate according to your standard office policies and procedures.

  1. View the HL7 ID Column and locate the adjustment code to change.
  2. Click on the adjustment code to highlight it.
  3. Click on the Edit button .
  4. In the ERA Auto-Match column, click on the dropdown arrow and select the Claim Adjust Code as the HL7 Code Group on the HIPAA Code Tables form. In the grid, you can manually override the default ERA Auto-Match setting for each HL7 ID code to one of the following status values:
  • Unmatched: Indicates the adjudication cannot be matched since the system cannot clearly identify the transaction being adjudicated. 
  • Matched: Indicates the adjudicated line does not require further review. This is the typical setting for adjudications where the payment and adjustment are consistent with the expected response from the insurance. 
  • Review: Indicates the item needs to be reviewed by the biller before it is approved. For example, adjudications with this setting may be part of a bundling that your practice may choose to challenge.
  • Appeal: Indicates that this adjustment code may require appeal because it indicates an error on the claim or there is a known payer response that your practice routinely appeals.
  • Denied: Indicates the adjudication has been denied by insurance. Transactions with this setting will have to be manually approved as Discard or Matched depending upon the intention of the user.
  • Paid: Indicates the claim was already paid. For example, this is the typical setting for a resubmission of a claim that was already processed.
  • Repriced: Indicates the claim has been reassessed by the insurance and is pending further action by the insurance and will need to be manually changed to Discard in order to process the adjudication.
  • Discard: Indicates the adjudication will be deleted from the table with no action taken once approved.
  1. Click on Post Edit button to save.
Note: The next time your office fetches an ERA, your system will auto-match any the claim lines to the Match Statuses that you have identified in this table.
Version 14.8
Path: Utilities Menu > Manage Codes > HIPPA Codes (Keyboard Shortcut keys: [Alt][U][C][H])

Overview

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.

If the characteristics of an item match, Office Practicum next determines the match status. Any line item that is matched, and whose numbers match perfectly (i.e., the full charge amount is accounted for, you received the amount of money you expected to receive, the patient paid the correct amount at time of service, and there is otherwise nothing unusual about the claim) is qualified for auto-approval. However, line items with payer-assigned adjustments require further review before simply accepting the payment and adjustment amounts. You would not want to accept a non-paid or reduced payment if the denial or reduction was based on a reason that may or may not be valid, or is based on a faulty claim submission.

To ensure that the auto-approval feature works as you intend, you should review the pre-assigned ERA Auto-Match values and adjust them (if necessary) based on your practice policies. It is recommended that your office view this list and confirm that the match settings are appropriate according to your standard office policies and procedures.

  1. View the HL7 ID Column and locate the adjustment code to change.
  2. Click on the adjustment code to highlight it.
  3. Click on the Edit button .
  4. In the ERA Auto-Match column, click on the dropdown arrow and select the Claim Adjust Code as the HL7 Code Group on the HIPAA Code Tables form. In the grid, you can manually override the default ERA Auto-Match setting for each type to one of the following status values:
  • Matched - Accept without further review, because the adjustment code is routine and does not require additional action, such as "Charges exceed your contracted amount".
  • Review - Indicates the item needs to be reviewed by the biller before it is approved. For example, the item is part of a bundling that your practice may choose to challenge.
  • Appeal - Indicates that this adjustment code would usually be appealed because it indicates an error on the claim (procedure inconsistent with patient's gender) or a known payer policy that your practice always appeals.
  • Paid - The status implies the claim was already paid, as is the case in resubmission of a claim that was already processed.
  • None - Indicates no default match status; biller must specify at time of approval.

  1. Click on Post Edit button to save.
Note: The next time your office fetches an ERA and auto-matches, any CPT lines identified as adjusted under this code will be set to review (or Matched or whichever status you previously identified).