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Claim Follow-Up - PM

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​Overview

Update, void, or replace closed claims. This form allows you to track denied claims that could possibly be re-billed once the denial reason has been resolved.

myAvatar PM > Billing > Remittance Processing > Claim Follow-Up

The following are examples of denials that could potentially be re-billed for reimbursement:

  1. An invalid diagnosis was submitted on the claim
  2. A claim was submitted without a prior authorization number
  3. The subscriber policy number submitted with the claim is invalid

Claims that require follow-up actions (review chart, contact payer, contact subscriber, etc..) are tagged in this form with a follow-up date, follow-up status, data entry by and date of entry. Comments can also be added to each follow-up action to document what occurred.

In addition to using this form to track claim follow-up actions, the Claim Follow-Up form can be used to assign a claim for electronic re-billing (in the Electronic Re-Billing Service Assignment form).

Logic has been developed that enables the 835 posting to file denial information in the Claim Follow-Up form upon posting an 835 when using the 835 Health Care Claim Payment/Advice form. The Payer Claim Control Number (PCCN) reported in CLP-07 of the 835 will be stored and displayed in the Denial CRN # field.

Note: The 835 information is required for the electronic re-bill functionality to work, and is available for 835s posted after the Claim Follow-Up registry setting is enabled.

  1. In the Add, Edit, or Delete Claim Follow-Up field, select Add to create a new claim follow-up. Select Edit or Delete to modify an existing claim follow-up.

  2. In the Select Claim Follow-Up to Edit or Delete field, select the existing claim to modify.
    Note: 835 Claims with a denial reason code defined as Compiled but Not Posted will automatically generate a claim follow-up and display in this field.

  3. In the Guarantor field, select the guarantor.

  4. In the Claim field, select the claim to follow up on.

  5. In the Denial Type field:

  • Select Full to work with all services on the denied claim.
  • Select Partial to choose the services to work with (in the Service(s) field).

  1. In the Service(s) field, select the services for the follow-up.

  2. The Amount Billed field displays the amount billed to the selected claim.

  3. In the Insurance Based Denial Reason field, select the reason the original insurance claim was denied.
    The extended dictionary data element, 11520 - Denial Reason Category must be defined for this dictionary.

  4. In the 835 Denial Reason field, select the reason the original 835 claim was denied.

  • This field performs the following:

    Determines if denial information from the 835 will be stored in the claim follow-up SQL tables.
    Posts the denial reasons to the tables, but does not affect the Client Ledger.
    Keeps the     charge balance remains so future payment after re-billing can be posted against the charge

  • The denial codes entered in this dictionary must have a claim adjustment group/reason code defined.
    Yes must be selected in the Compile but do not post adjustments (CAS) associated with the indicated Claim Adjustment Group/Reason codes when processing an 835 field in the Claim Adjustment Group/Reason Code Definition form.
    This field is enabled through the Compile But Do Not Post Adjustments (CAS) registry setting. 

  1. In the Assign Claim for Electronic Re-Billing field, select Yes to flag the claim for electronic re-billing.
    Note: This option is only available for claims created by an 837 filing.
    Yes should be selected when processing for the denial is finished. This will allow the denial to be included in the next billing run, for 837 claims.

  2. In the Claim Submission Reason Code field, select the reason for the re-billing.
    This is only available for 837 claims.

  • Corrected (Adjustment of Prior Claim) - Used in cases where the prior claim is being adjusted.
  • Replacement (Replacement of Prior Claim) - Used in cases where the prior claim is being replaced entirely.
  • Void (Void/Cancel of Prior Claim) - Used in cases where the prior claim must be voided or canceled.

  1. The Date Status Followed-Up Denial CRN#/Current CRN# field displays the history of follow-up information entered for the claim.

  2. In the Add, Edit, or Delete Row field, select Add to create a row for new follow-up information. Select Edit or Delete to modify an existing row.

  3. In the Select Row to Edit or Delete field, select a row to modify.

  4. Click the Update Row button to submit the current row information. If Delete was selected in the Add, Edit, or Delete Row field above, this will delete the selected row. In the Follow-Up Date field, enter the date of the follow-up.

  5. In the Follow-Up Date field, enter the follow up date.

  6. In the Follow-Up Status field, select the follow-up status.

  7. In the Followed Up field, select Yes if the follow-up is completed, and to flag the claim for re-bill (837 claims).

  8. In the Denial CRN# field, enter the denial CRN#.
    This field displays the denial claim reference number (the original claim reference # / PCCN #.) Posted 835 files populate this field.

  9. In the Current CRN# field, ether the current claim reference number.

  10. Enter any comments in the Comments field.

  11. The Date of Entry and the Data Entry By fields display the date of the last entry and the name of the user who made the entry. These fields are display-only, and will only populate when an existing row is selected (in the Select Row to Edit or Delete field).

  12. When finished, click Submit.

► SQL Tables

  • SYSTEM.claim_follow_up_data
  • SYSTEM.claim_follow_up

► Registry Settings

  • Change Claim Field To Multiple-Select

  • Claim Follow-Up