Retro Claim Adjudication

You can manage claims in closed batches. These claims have been checked and paid. You cannot add more services to a claim that has old payments (retro claim adjudications) on file. If you remove an old payment (retro claim adjudication), you will remove all the old payments for that claim.

Prerequisites:

• User must be assigned to a User Role authorized to (run, file/submit, view) Retro Claim Adjudication.  
• User must be logged into myAvatar.  
• A previously approved claim must need to be “taken back” for any applicable reason.
• A claim must be entered in a batch (Batch Creation form).

1. ---

   Go to: Avatar MSO > System Maintenance > Retro Claim Adjudication
2. In the Add/Edit/Delete Claim Adjudication table, select Add.
3. In the Batch Number field, enter the batch number, and select.
4. In the Member Name or ID field, enter the member name, and select.
5. In the Provider field, enter provider name, and select.
6. The Claim and Date of Service fields display claims and services associated with the batch, member, and provider.
   • In the Claim field, select the claim.
   • In the Date of Service/Procedure field, select the service or procedure.
7. The Original fields display fees associated with the original service in the claim.
   • Original Service Fee - displays the service fee.
   • Original Member Co-Pay - displays the member's co-pay.
   • Original Member Deductible - displays the member's deductible.
   • Original Disbursement Amount - displays the original disbursement.
   • Original Third Party Payment - displays third party payment (if any).
8. In the Update fields, enter service fee information to update the service.
   • Updated Service Fee- If the claim is filed in the SYSTEM.retro_claim_adjudications table, the associated updated fee defaults. If the claim is being added to the SYSTEM.retro_claim_adjudications table, the current service fee, from the Provider Fee Table, defaults.
     This value can be edited by the user.
   • In the Updated Member Co-Pay field, enter the member's co-pay.
   • In the Updated Member Deductible field, enter the deducible.
   • In the Updated Disbursement Amount field, enter the service fee minus the deductible or co-pay.
   • In the Updated Third Party Payment field, enter the third party payment (if any).
   • In the Adjustment Code field, select the adjustment code to associate with the take back amount.
9. In the Take Back Amount field, enter the amount:
   • Enter a positive for an overpayment.
   • Enter a negative amount for an amount owed.
10. In the Withold Payment field:

• Select Yes to factor the value entered in the Take Back Amount field in both the EOB and the 835 file.
• Select No to exclude the value entered in the Take Back Amount from the EOB.
  This amount will be included in the 835 file.

10. In the Comments field, enter comments associated with the claim adjudication.
11. Select Update Claim Adjudication.

► Screenshot

► SQL Tables

• SYSTEM.retro_claim_adjudications