Default Adjudication Match Status

Version 20.13
Path: Billing tab > More button (Reference Data group) > HIPAA Codes > Claim Adjust Code radio button

About

The defaulted Match Status that is populated when posting adjudications is determined by the selections made in the HL7 Code Group: Claim Adjust Code grid. The ERA Auto-Match column determines the default for each Claim Adjust HL7 ID Code. It is recommended that your office review the pre-assigned ERA Auto-Match values, and confirm that the selection for each adjustment code is appropriate according to your standard office policies and procedures. Below, you'll learn:

ERA Auto-Match Options

  • 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, adjustment, and patient responsibility amounts 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 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 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 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 payer. This needs 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.

Edit the Default Match Status

Edits can be made to the default Match Statuses at any time. However, they will not be applied to adjudications that have already been brought into OP. All changes are applied the next time your office fetches adjudications.

  1. Navigate to the Claim Adjust Code grid in the HIPAA Code Tables by following the path above.
  2. In the HL7 ID column, click to select the Adjustment Code.
  3. Click the Edit button .
  4. In the ERA Auto-Match column, select the default Match Status setting from the drop-down menu.
  5. Click the Save button  when finished.

Overrides to ERA Auto-Match Selection

The following Match Statuses are populated for adjudications regardless of what is selected in the ERA Auto-Match column:

  • When an adjudication will cause the claim to be out-of-balance, the default Match Status is overridden to Discard. The Aprvd checkbox for these transactions is highlighted in yellow to alert the user that the line is out-of-balance and must be discarded and manually posted.
  • When an adjudication line has matching Charge and Adjustments amounts, the default Match Status is overridden to Review. This prevents accidental full charge write-offs.
Version 20.12
Path: Billing tab > More button (Reference Data group) > HIPAA Codes

Overview

If the characteristics of an ERA line 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 the 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 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. Navigate to the HIPAA Code Tables by following the path above.
  2. If it is not already selected, select the Claim Adjust Code radio button.
  3. Click to select the Adjustment Code.
  4. Click the Edit button .
  5. Select the Claim Adjust Code from the drop-down menu in the ERA Auto-Match column. 
  6. Select the default ERA Auto-Match setting for each HL7 ID code:
  • 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, adjustment, and patient responsibility amounts 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 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 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 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 payer. This needs 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 the Save button  when finished.

NoteThe next time your office fetches Adjudications, your system auto-matches any of the claim lines to the Match Statuses that you have identified in this table. However, if an out-of-balance transaction is identified, the Aprvd checkbox is highlighted in yellow the default Match Status on the claim line will be overridden and set to Discard. That transaction will then have to be manually posted.