Category: G5

Recording Claim Adjustment Reasons for Denials or Payment Reductions

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In order to successfully file secondary insurance, your Credit entries for the primary insurer, whether payments, adjustments, or denials, must include Claim Adjustment Reason codes to document how the primary processed the claims. Even when the primary payer made a payment, it will often be reduced by amounts referred to as “claim adjustments.” The specifics of these adjustments are critical to the secondary payer, so as you enter the primary payer’s payment, adjustment, or denial, it is essential that you also record the the Claim Adjustment Reasons (CARs) that appear on the primary payer’s Explanation of Benefits (EOB).

NOTE that there is no reason to enter Claim Adjustment Reasons unless you are submitting secondary claims for this patient and service.
  1. Start by entering a credit as you normally would. Highlight the charge you are paying and click Apply Credit to open the Credit Split window. Notice the second tab, Claim Adjustment Reasons.
  2. Before saving the Credit Split, be sure to select the Claim Adjustment Reasons tab and complete it using the information in the primary payer’s EOB, as explained in the steps below.

  3. The next step is to decide what the total amount of the adjustments is and what dollar amount is accounted for by each of the individual CARs. Here is a simple rule to use to determine what the total amount of the CARs will be:

    Service Fee  –  Primary Insurance Payment = Total CARs

    Example One: Your fee for a service is $150.00; the primary insurance company paid $80.00. If you subtract $150.00 – $80.00 you are left with $70.00. All of the Claim Adjustments (CARs) for the primary payer should total $70.00.

    What is accounted for in the CARs? The CARs are the reasons given by the payer for not paying your entire fee. You must enter the primary payer’s reasons and the specific adjustments or transfers so that the primary payer’s CARs can be included in the secondary claim. You will indicate if there was an adjustment made by the primary insurance for contractual reasons, if there was a patient responsibility for the service, if there was a disallowed amount, or any other reason the primary payer indicates.

    To continue the example from above: The fee for the service is $150.00 and primary insurance paid $80.00. The primary insurance contractually allows only $110.00 for the service provided so they made an adjustment of $40.00. The patient had a copay of $10.00 on this service and coinsurance of $20.

    Using the formula above,

    FEE – PRIMARY PAYMENT = CARs

    $150.00 – $80.00 = $70.00 ($40.00 + $10.00 + $20.00)

    So we are now ready to enter the information in Claim Adjustment Reasons. After selecting the Claim Adjustment Reasons tab, click the New button on the toolbar or press <CTRL>-<N>.

  4. On your EOB, you will see that each adjustment has a Group Code and a Reason Code. To enter the $40 adjustment, select the Group Code “CO” for “Contractual Obligations” from the drop list. In the first Reason panel select code “45” (“Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule”). Under Amount, enter “$40” and under Total Unit Paid, enter “1”. In this example, there are no additional reason codes for Group CO, so save the screen and open another by clicking the Save and New button in the toolbar at the top of the window.

  5. In this example, our EOB also lists a patient copay of $10.00 and  patient coinsurance of $20. You will enter “PR” as the Group Code for “Patient Responsibility.” In the first Reason panel, use code “3” (Copay amount) and “$10.00”. The Total Unit Paid will be 1. In the second Reason panel, enter code “2” (Coinsurance Amount), “$20.00” and Total Unit Paid, as usual, is “1”.
  6. Save and close, taking you back to the Claim Adjustment Reasons list. There you will see:
    Group Code Total Amount Total Unit Paid
    PR $30.00 2
    CO $40.00 1

    The claim now balances. you have accounted for the full amount of the fee ($150) with your payment of $80 and your claim adjustments of $30 and $40.

Example Two: The fee for the service is $150.00 but the primary insurance did not pay anything because it went towards the patient’s deductible. $150.00 – $0.00 = $150 (Fee – Primary Payment = CARs), so your CARs must  account for the full $150.00. The EOB indicates the same maximum allowable for the service as in Example One, $110.00. The EOB indicates nothing about copay. So you will enter a $40.00 fee adjustment (Group CO, Reason Code 45) and the remaining $110 as Group PR, Reason Code 1 (Patient Responsibility). The total CARS will equal $150.00. Your Claim Adjustments screen will show:

Group Code Total Amount Total Unit Paid
PR $110.00 1
CO $40.00 1

Qualifying Your Credit Type Selection for Payments and Adjustments

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When entering a new payment in the Credit form, you must select a payment type from the drop-list.

Depending on your choice, an additional field will appear on the screen to collect appropriate information, as shown below:

Credit Type Adjustment

Credit Type Cash

Credit Type Credit Card

Credit Type Check

Credit Type Denied

Credit Type EFT

Credit Type Other

In each case, the next step is to click the new field to open a selection list. In some cases, the list will display available options. For example, Adjustment type and Denied type will reveal lists showing choices that were preconfigured from Billing Lookups > Other Billing Lookups in the Navigation bar. In addition, the user can add a new Adjustment or Payment Denial reason code by clicking the New button in the lower right corner of the pick list.

Pick lists for each of the other types (Cash, Credit Card, Check, Electronic Funds Transfer, and Other) all behave in a similar fashion. For example, the list for a Check payment will contain any previously entered checks from the current payer that still have an undistributed amount, but whether some existing checks appear or not, you can add a new check by clicking the New button in the lower right corner.

Note that in SOS G5, even cash payments must be logged and recorded with an optional description and a system generated voucher identifier. Once entered in SOS, the cash payment can be managed in exactly the same way as a check payment. For example, amounts from a single large cash payment can be distributed and tracked across multiple credit entries, and even used to make payments against several different patient accounts that share a common payer (like a parent who is configured as the payer for a spouse and/or several children). Credit types Other and Electronic Funds Transfer work the same way as well.

Using Quick Add to Rapidly Create a New Patient Account

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Adding a complete, new patient account requires time and effort. It may include:

  • Identifying and demographic information.
  • Multiple addresses, phone numbers, and emails.
  • Emergency and other patient contacts.
  • Primary, plus one or more secondary insurance information.

Getting all this information entered can require navigating to multiple screens and countless fields. Sometimes all you want to do is get the most essential data entered as quickly as possible, knowing that you can always come back later to add supplemental information.

To this end, SOS provides Quick Add – just the essentials on one compact screen.

From any of the Patient List screens, click the Quick Add button in the top toolbar. Complete the basic identifying and demographic fields, then, if there is insurance coverage, select the appropriate plan from the drop-list. If you can’t find a matching plan in the list, use the New button at the lower right corner of the list to create a new one, then select it. The essential insurance policy fields will then appear, as will a handful of Claim Setup fields. Fill in what you can in both panels.

Repeat for secondary insurance coverage, if any. Check your input for the entire page and when ready click OK to save and close the form. Note that Quick Add cannot handle a third insurance policy, but after saving, you can open the new patient account from the Patient List and add as many additional policies as you wish.

Note that the Quick Add form is just for initial account creation. Any subsequent review or modification must be done from the Patient List.

Complete patient entry:

Entering a New Patient, Step 1: Open the Appropriate Patient Form
Entering a New Patient, Step 2: Basic Demographic Data Fields
Entering a New Patient, Step 3: Patient Communications
Entering a New Patient, Step 4: Contacts

Running Provider Payroll

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IMPORTANT: Your payroll results include only payments that have been applied to specific charge entries. Unapplied payments will be ignored.

Running payroll consists of selecting desired payment entries, generating a report, and, if the report is correct, processing the report to your SOS accounting records:

  1. Click Payroll under Billing in the Navigation panel. A list will appear containing all the payroll-eligible credits that have not yet been processed. Only credits that have been posted to patient ledgers will appear in this list. Those remaining in the Daysheet cannot be processed and therefore do not appear on the Payroll list.

  2. You can, and should, apply appropriate list filters so that only those providers and credits you want to process appear in the list. For example, if you want to include only payments made during a particular date range for this payroll, create the appropriate filter for the Transaction Date column of the list. There are many options for date filtering available to you. Filtering for just certain providers is even easier. Just move your mouse pointer to the upper right corner of the Provider Name column heading (which, by default appears in the “Group By” area at the top of the list), then click the funnel icon that will appear there. A list of providers will appear and you can check the boxes next to the ones you want to keep in the list.

  3. If you do not see the individual credits listed onscreen, double click each Provider Name line in the list (or the little plus sign to the left of each provider group heading) to toggle the details display.
  4. You must now tag (highlight) the content you want to include in your payroll. If your Payroll list contains exactly what you want to report and process, press <CTRL><A> or click the double map pin icon in the tool bar to instantly tag everything in the list.

  5. Once you have tagged one or more payroll items, the print and process icons in the toolbar will be enabled. SOS recommends that you use the Review/Print Preview button to review the results before going on to the Process Payroll button. There is no way to undo payroll processing, so carefully check the Preview before proceeding!!

     

  6. Generate the payroll preview report, using the first button on the toolbar.
  7. Review the report carefully.
  8. Use the second button on the toolbar to process the payroll as displayed. You cannot reverse this operation, which is why the review step is so important.

Check your system options to be sure you have indicated whether to report payroll by rendering or primary provider. In SOS G5, the primary provider is specified on the patient’s Care Episode, and each Charge entry includes a drop list to assign it to the desired Care Episode. The rendering provider, by contrast, is the provider selected on each Charge entry.

To put it another way, select the Primary Provider option if the patient’s primary provider on her Care Episode is the one who should receive payment. See below for the location of the Primary Provider field on the Care Episode details page:

On the other hand, if you want to pay the provider indicated on each Charge, regardless of the named PrimaryProvider, then be sure to select Rendering Provider in the payroll report’s options. Doing so will cause the report to filter based on the provider indicated on your Charge entry screen:

See also:

How to Correct Payroll Errors

How to Generate Secondary Claims

Posted on | by SOS Blog

In the normal course of events, SOS will automatically queue up claims for the secondary payer as soon as the balance on the primary insurance drops to zero due to payment, adjustment, or transfer. If there is a tertiary payer, it will follow when the secondary is completed, and so on. 

The exception is when the charge fee amount is zero, but it is still necessary to generate a claim. In that case, the secondary insurance won’t generate a claim unless you manually mark the primary insurance claim for the charge as “paid.” Here is how that is done:

  1. In the main Navigation bar, open the Claims section and click Outstanding Zero Splits.
  2. The Outstanding Zero Insurance Splits list will appear. Tag one or more charges in the list. Use the push-pin buttons in the toolbar or the standard Windows tagging methods of click, CTRL-click, SHIFT-click and so on. In the web browser version of G5, check the boxes to the left of the desired lines.
  3. Once you have tagged desired lines, click the dollar-sign button in the toolbar.
  4. Any charges for which there is a secondary payer will now be queued for billing in the next insurance batch for which it qualifies.