We are currently updating the OP Help Center content for the release of OP 14.19 or OP 19. OP 19 is a member of the certified OP 14 family of products (official version is 14.19.1), which you may see in your software (such as in Help > About) and in the Help Center tabs labeled 14.19. You may also notice that the version number in content and videos may not match the version of your software, and some procedural content may not match the workflow in your software. We appreciate your patience and understanding as we make these enhancements.

Processing an Insurance Retraction, Takeback, or Recoupment

Version 14.19

Overview

In some cases, insurance companies will take money back on Claims that they have partially or fully paid to a Provider, due to, but not limited to the following:

  • Paid in Error
  • Benefits were retro-terminated
  • Additional information requested

Insurance payment retractions can be handled by the payer in one of two ways indicated below.

Processing Retractions

Scenario 1: The payer requested a refund check.

  1. Open the Patient Chart for the Patient whose payment the Payer is retracting. 
  2. Click Summary to review the patient's Insurance Credits. 
  • If there is an insurance credit, visit the Credits in the patient chart to ensure the credit can be used and proceed to Step 6.
  1. If the money is not sitting as an Insurance Credit, click Claims
  2. Select the Claim whose payment is being retracted.
  3. Click the Recoup button to delete the corresponding insurance payment and adjustment. An Insurance credit will be created.
  4. Click Credits.
  5. Click the Refund button.
  6. Select Refund Check from the Refund Method drop-down menu.
  7. In the Refund from Insurance Credit field, enter the amount that you are issuing back to the payer.
  8. Enter the refund check information in the Note field for your records.
  9. Select the Provider on the Claim.

  1. Click the Save/Post button when completed.

Scenario 2: The payer is retracting a payment and applying it to another patient on a remit.

The payer can enter the retraction on an EOB with payments for other patients, then reduce the check by the amount of the retraction. If this is the case, follow these steps:

  1. Open the Patient Chart for the Patient whose Payment the Payer is retracting. 
  2. Click Summary to review the patient's Insurance Credits.
  • If the original payment is already applied to a Claim and not yet entered as an insurance credit, see Un-applying a retracted insurance payment. The original payment being retracted needs to be an Insurance credit.
  1. When the remit containing the retraction is received, open the Patient Chart for a patient that is being paid on the remit.
  2. Click Credits.
  3. Click the New Credit button.
  4. From the Pay method drop-down menu, select Insurance Transfer.

  1. In the Debit Patient field, use the Patient Search button to search for and select the Patient to debit insurance credits from. The patient's name and amount available for transfer will populate in the table.
  2. In the Transfer field, enter the Amount to transfer.
  3. Click the Ins button to select the payer.
  4. Enter the Details of this transfer in the Note field. Details may include EOB number and a brief explanation as to why the Patient received an Insurance Transfer.
  5. Once the credit is entered, you can apply the credit as a Payer Credit to the patient's claim.
Version 14.10
Path: Smart Toolbar > Account button

Overview

In some cases, insurance companies will take money back on Claims that they have partially or fully paid to a Provider , due to, but not limited to the following:

  • Paid in Error
  • Benefits were retro-terminated
  • Additional information requested

Insurance payment retractions can be handled by the payer in one of two ways indicated below.

Processing Retractions

Scenario 1

  1. From the Smart Toolbar, click the Accnt button 

  1. Search for the Patient .
  2. If the money is not sitting as an Insurance Credit on the account, click the Claims tab .
    (if there is insurance credit already on the child's account, skip to Step 6).
  3. Click on the Claim that money is being retracted and click the Recoup button to delete the corresponding insurance money. Clicking on Recoup will remove all corresponding Insurance payments and adjustments and create an Insurance credit on the Credits tab of the Patients Account.
  4. If the insurance is requesting a check back for the recoupment, click the Credits tab.
  5. Click the Add Refund button.
  6. From the Refund Menu drop-down menu, select Check.
  7. Enter the Amount that you are issuing back to the payer in the Refund from Insurance Credit field.
  8. Enter the Refund Check Information in the Note field, for your records.
  9. Enter Data in the rest of the Fields as applicable.

  1. Click the Save/Post button when completed.

Scenario 2

The payer can enter the retraction on an EOB with payments for other patients, then reduce the check by the amount of the retraction. If this is the case, follow these steps:

  1. Open the Child's Account that the money is being recouped from. If the original payment is already applied to a claim and not yet entered as an insurance credit, see Un-applying a retracted insurance payment.The original payment being retracted needs to be in the Patient's Account as an insurance credit.
  2. When you receive the EOB with the retraction, open the Patient's Account for a patient that is being paid on the EOB.
  3. Open the Credits tab on the Patient's Account.
  4. Click the Add Credit button.
  5. Select Insurance Transfer from the Pay Method field. 
  6. Select the Debit Patient search to choose the patient to debit insurance credits from.
  7. Enter the Details of this transfer in the Note field. Details should include EOB number, a brief explanation of why this child received an Insurance Transfer. Once the credit is entered, you can apply the credit as a Payer Credit pay method to the claim paid on the EOB.