Work on Claim Errors and Rejections

After you prepare and submit claims, you must deal with claims that could not be submitted or were rejected.

Your PCC system automatically catches many problems before a claim leaves your practice; it holds back claims that contain errors or otherwise need corrections. After submission, a payor may not accept a claim because they can’t identify the subscriber or for some other reason.

In order to get paid, your practice must address both claims that couldn’t be submitted and rejected claims. Read below to learn about tools for working with claims that need corrections or were rejected.

Review Claims that Need Corrections

After you prepare and submit claims, you can immediately review all claims that need corrections.

You can work your way down the list and open the corresponding patient chart in PCC EHR, or you can use Correct Mistakes (oops) in Practice Management to address the error. The claim will then go out when you next prepare and submit claims. Claims that needed corrections are also logged in the Log tab of the Claims tool.

For more information about using the Need Corrections and Log tabs in the Submit Claims tool, read Submit Claims.

Read Electronic Remittance Advice From Payors

You can review all ERAs from payors in the Electronic Remittance Advice tool.

ERAs provide complete details about the payor’s adjudication, including payments, adjustments, denials, and unusual circumstances. Read the Read ERA 835s from Payors article to learn more.

Review Claims that Need Corrections and Claim Rejections in the SRS Billing Error Report

Use the SRS Billing Error Report to work on claim rejections. The report also displays claims that couldn’t be submitted, in case any were missed in the Claims tool.

The Billing Error Report uses SRS, a powerful and customizable reporting tool.

By default, the Billing Error report displays claim processing errors (“Tagsplit” errors), clearinghouse rejections, and payer rejections. It sorts the results by responsible party and then by billing status. You can use the Correct Mistakes (oops) program to review the account and read more about the error, update charge information, and resubmit a claim.

Most Recent Status is Not Always Correct: The Billing Error report in srs displays claims based on their most recent status. However, payors sometimes mistakenly send a claim denial, followed by a claim acceptance. The claim was “accepted” for adjudication and also denied, but the most recent message makes it appear the claim is still being processed. For this reason, PCC recommends you periodically run the Insurance Company Accounts Receivable (inscoar) report to find outstanding unpaid claims.

For more information on fixing problems and generating a new claim, read Correct a Claim: How to Fix and Resubmit an Insurance Claim. For more general information about editing charges and reviewing the full details of a claim rejection or response, read Adjust Charge, Payment and Claim History.

Review Unpaid Balances with Advanced Reporting Tools

The steps above will ensure that you address all claims that had errors or that were rejected. And, when you review and post incoming ERAs, you can troubleshoot claim denials.

However, what if a problem was fixed, but a claim was never resubmitted? Or what if a claim issue occurred outside the range of a log or a report? How can you follow up on claims if the payer simply never responds? Insurance claims are not always paid, and insurance carriers do not always send you an explanation. Therefore, you may need other tools to track and work down your practice’s insurance A/R.

• View an A/R Overview: Use the Insurance Company Aging Report (insaging) report to get an overview of how major insurance groups are performing and to evaluate your total outstanding accounts receivable.

• Work on A/R, Claim-by-Claim: When you want to review all unpaid, pending charges, regardless of their billing status, use the Insurance Company Accounts Receivable (inscoar) report to find exactly which charges are not yet paid, but still pend an insurance payer.