Process Adjudications on the Unmatched Tab

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

Overview

The top half of the Unmatched screen will include adjudications that are unmatched because OP was unable to clearly identify the patient and/or CPT. This could happen for several reasons, such as:

  • The claim was originally billed in another billing program (other than OP). 
  • The claim adjudication is listed under the name of the insured as opposed to the patient (e.g. for newborn claims).
  • The claim adjudication is for a CPT/claim that no longer exists on the corresponding patient account (e.g., if a claim was billed and sent electronically, then identified as billed incorrectly in OP and corrected; payment will come in under the original CPT/claim number that no longer exists if the user previously corrected the problem).
  • The claim adjudication is slightly different than the original claim (e.g., the adjudication contains a modifier that does not exist on the corresponding claim in OP).
  • The claim adjudication is for a current claim as a result of daysheets not being processed. When OP attempts to match adjudications to claims, it is checking for archived transactions only as the assumption is that if a payment is being received, the corresponding date of service has already been "closed". 

You must match these adjudications against existing transactions so that they move to the Matched tab for review and processing as follows:

  1. Click on the Billing Icon on the Smart Toolbar.

Smart Toolbar: Billing

  1. Click on the Adjudications tab.
  2. Click on the Unmatched Tab.

  1. Match the adjudication to an existing claim/transaction.
  • Option 1:
  1. On the lower half of the screen, you will find a list of possible matches, as defined by OP (based on the patient name, cpt billed and date of service).
Note: The list of possible matches are, again, looking at archived claims so if the reason that adjudication is unmatched is because daysheets have not been run for these dates of service, it is suggested that you run daysheets to archive these transactions. Once the daysheets have been run, OP should list the patient in the lower portion of the screen as a possible match.
  1. If the matching transaction is located in this portion of the screen, double-click on it. This will auto-populate the Match Transaction box (in the center of the window) with the corresponding transaction number.
  • Option 2:
  1. If the matching transaction is not located in the lower half of the screen, open the Patient's Account, and then click the Claims button to review the Patient's claim history.

  1. Locate the specific transaction and double-click on it to access the Claims Details: Linked Charge Transactions window to view the CPT codes Transaction number, copy that Transaction # and close the window.

  1. Go back to the Adjudications Unmatched tab and locate and record the number in the Transaction # field, then manually enter the transaction number in the match transaction box located in the center of the Unmatched window. 

  1. Regardless of how the match transaction box was populated, click the Match button in the center of the window.
  2. Click Yes in response to OPs prompt to confirm that you are requesting an adjudication match.


The matched adjudication will now disappear from the Unmatched tab, and appear under the Matched tab for your review and approval, as applicable.