Referrals & posting payments

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drk
Posts: 155
Joined: Sat Oct 11, 2014 11:40 am
Location: Boston, MA

Referrals & posting payments

Post by drk » Mon Mar 23, 2015 10:25 am

Tufts Health Plan, when they deny a claim for lack of referral (CO165), post an adjustment for the entire amount of the claim. Now, after we get a referral, reprocess the claim and get paid, all payments show up bright yellow as overpaid.

We can either: Not post the initial denial and post only the payment OR delete the original denial when the payment comes through.

Either approach has its problems - In the first case, it is hard to tell that there was no payment for this claim and easy to miss the zero payment, and in the second, you lose the historical data.

What is the preferred way to handle this? It gets more complicated as different payers handle CO165's differently on the ERA. I would like to have a uniform approach, if possible.

Andrew
Posts: 153
Joined: Tue Mar 19, 2013 3:24 pm
Location: Springfield, MO
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Re: Referrals & posting payments

Post by Andrew » Mon Mar 23, 2015 2:18 pm

What you could do is create a new posting code as a comment. Then you can post the data without actually posting it as a payment or adjustment. This just allows it to be posted as a comment and does nothing with the actual balance.
Andrew Analla
Support Team
MedTech Medical Management Systems
3058 S Delaware Ave
Springfield, MO 65804
Ph: 417.890.6777 | Fax: 417.890.6788

drk
Posts: 155
Joined: Sat Oct 11, 2014 11:40 am
Location: Boston, MA

Re: Referrals & posting payments

Post by drk » Mon Mar 23, 2015 4:09 pm

Thanks for the response, not sure I follow -- Let me try -- Create a posting code, and reclassify all the lines in the denied EOB (0 payment and all adjustments) to this one code?

Andrew
Posts: 153
Joined: Tue Mar 19, 2013 3:24 pm
Location: Springfield, MO
Contact:

Re: Referrals & posting payments

Post by Andrew » Mon Mar 23, 2015 5:42 pm

Well any code you do not want to apply as a payment or adjustment you could apply as this one code. If you want you could make more descriptive codes for each type of situation. That is up to you, but a code that is a comment will not post any changes to the actual amount. It will just let you keep that information for future reference. When we setup RM for remits for example we set the Co insurance pay amount to comment so it will not post as a payment from that EOB same with Due co pay amounts. We create two separate posting codes and set them as comments. This way you can know what the amounts were for.
Andrew Analla
Support Team
MedTech Medical Management Systems
3058 S Delaware Ave
Springfield, MO 65804
Ph: 417.890.6777 | Fax: 417.890.6788

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