ERA processing logic - claim details level

Path: Transactions>General>ERAs

• Original claim is not voided:
  • If the original closed claim is not voided, then all payments, adjustments, and denial adjustments are applied to the corresponding claim details which are identified by the Item Date and HCPCS code, CPT code, or Revenue code.
• Original claim is voided:
  • If the original closed claim is voided, the system starts searching for the replacement claim by the following parameters: From and Thru dates, Patient ID, and Payer ID.
  • The From and Thru dates of the replacement claim should be within the date range of the original claim, but should not necessarily coincide.
  • For example, the original claim could be June 1 – June 30, and the replacement could be June 1 – June 25, or June 3 – June 29, etc. The Patient ID, Payer ID, and Item Date should coincide precisely.
• When the replacement claim is found:
  • If all replacement claims were previously paid on the details level, the payments, adjustments, and denial adjustments are applied to the replacement claim details which are identified by the Item Date and HCPCS code, CPT code, or Revenue code.
  • If at least one detail is not matching the replacement and the Apply Payments/Adjustments to voided claim if appropriate replacement is not found check box is selected, the details' payments, adjustments, and denial adjustments are reassigned back to the voided claim only if this voided claim was previously paid on the details level.
  • If this voided claim was not previously paid on the details level or if the Apply Payments/Adjustments to voided claim if appropriate replacement is not found check box is not selected, the payments, adjustments, and denial adjustments are not applied and the "Claim detail line exists but does not match any service record from the application based on date range, Revenue, HCPCS, or CPT codes" error message is shown.
  • If at least one replacement claim was previously paid on the claim level, the system rolls the matching details back and rematches them on the claim level (based on From-Thru dates parameter).
  • If the replacement claim processing results in errors, these errors are reported under the original voided claim record (the system does not try to apply payments/adjustments back to the original voided claim).
• When the replacement claim is not found:
  • If the Apply Payments/Adjustments to voided claim if appropriate replacement is not found check box is selected, the system tries to reassign payments, adjustments, and denial adjustments to the voided claim.
  • If the voided claim was previously paid on the details level, the payments, adjustments, and denial adjustments are applied on the details level.
  • Otherwise, the payments, adjustments, and denial adjustments are applied on the claim level.
  • If the Apply Payments/Adjustments to voided claim if appropriate replacement is not found check box is not selected, the system does not apply payments, adjustments, and denial adjustments back to the voided claim.