How do I fix a claim(s) held in billing review?

A visit is held in billing review until all problems are corrected. All visits need to meet rules designated by the payer before you can print invoices or submit e-claims.

  1. Go to Admin > Contract Setup > Search Contract.

  2. Enter search parameters and then select the applicable contract.

  3. Under Billing/Collections select the Export/Print Validations for E-Billing and/or Paper Invoicing link.

  4. Check the following selections in the window that opens to determine the requirements for the visit:

    Billing Export Requirements selections

    • Apply to Export Process: complete these requirements to add visits to e-billing.

    • Apply to Paper Invoice Process: complete these requirements to add visits to paper invoicing.

  1. Go to the Billing > Billing Review.

  2. Select Detail View.

  3. Enter search parameters and then select Search.

    Billing Review On hold reasons

  4. To resolve billing review issues, find the On Hold Reasons from the list below and follow the instructions in the resolution column.

    Once the issue is corrected, the visit is removed from the billing review and can be added to an e-billing batch or a paper bill.

Problem

Resolution

  • Missing Patient Name

  • Missing Patient Address

  • Missing Patient City

  • Missing Patient State

  • Missing Patient Zip Code

  • Missing Patient Date of Birth

  • Missing Patient Gender

  • Missing Patient SNN

  • Medicaid Number must be 8 characters

  • Miss Patient MR Number (appears as Patient ID)

  1. Select the patient from the Consumer Name column.

  2. Click the Edit button located at the bottom of the Consumer Profile page.

  3. Enter the missing patient information in the corresponding field(s).

  4. Click Save.

  • Alt Patient Number should not be blank

  • Alt Patient ID must be 11 characters

  • Missing Contract Start Date

  1. Select the patient from the Consumer Name column.

  2. Click the Contract page link from the left navigation index in the patient's profile.

  3. Click the Edit link in the Alt Patient ID or Service Start Date column.

  4. Enter a value for the Alt Patient ID or the contract Start Date.

  • Missing Primary Diagnosis

  1. Select the patient from the Consumer Name column.

  2. Click the MD Orders link from the left navigation index in the patient's profile.

  3. Click the Add button to enter a new MD order or click the MD Order ID link to edit an existing one.

  4. In Section 11 Primary DX, click the Add button to enter the patient's diagnosis.

  • Missing Authorization Number

  1. Select the patient from the Consumer Name column.

  2. Click the Authorization/Orders link from the left navigation index in the patient's profile.

  3. Click the Add button to enter a new authorization or click the Edit link to update an existing one.

Problem

Resolution

  • Visit Start/End Time cannot be blank

  • Missing Service Code

  • Visit cannot have TEMP Authorization

  • Missing Caregiver Name

  • Scheduled hours exceed Authorization

  • Schedule Duration does not match Authorized Hours

  • Billing by Export Code Greater than 24 Hours

  • Maximum hours should not exceed the limit specified

  1. Select the patient from the Consumer Name column.

  2. Go to Visits link from the left navigation index in the patient's profile.

  3. Use the search filters to locate the visit with missing and/or incorrect information.

  4. Click the Edit icon ( ) to open the visit window.

  5. Go to the appropriate tab to enter the required information.

  6. Click Save.

  • Missing Export Code

  • Missing Revenue Code

  • Missing Taxonomy Code

  1. Go to Admin > Reference Table Management.

  2. Select the Contract Service Code from the Reference Table dropdown field and select Search.

  3. Select the applicable Service Code.

  4. Enter the respective value in the Export, Revenue, and/or Taxonomy Code fields.

  5. Click Save.

  • Invalid CNR Import Reference Number

  1. Select the patient from the Consumer Name column.

  2. Click theCalendar link from the left navigation index in the Patient Profile.

  3. Click theV link on the calendar date cell to access the visit.

  4. In the Schedule tab, enter the correct CRN Import Reference Number.

  5. Click Save.

  • Missing Caregiver NPI Number

  • Missing Caregiver Professional License Number (PLN)

  1. Go to Caregiver > Caregiver Search and select the caregiver from the search.

  2. Click the Profile link from the left navigation index in the Caregiver Profile.

  3. Click the Edit button located at the bottom of the page.

  4. Enter the Caregiver NPI Number and/or the Caregiver PLN Number.

  5. Click Save.

Problem

Resolution

  • Missing CNR Employee Number

  1. Go to Caregiver > Caregiver Search and select the caregiver from the search.

  2. Click the Others link from the left navigation index in the caregiver's profile.

  3. Enter the caregiver’s CNR Employee number.

  4. Click Save.

  • Missing Physician NPI Number

  1. Go to Admin > Physician Setup > Physician Search and select the applicable physician.

  2. Enter the physician's NPI number.

  3. Click Save.

  • Pending Billing of Additional Shifts on Same Day

  1. Go to Action > Confirm Visits.

  2. Use the search filters to locate visits on the date in question.

  3. Confirm applicable visits and then click the Save link for each visit.

Problem

Resolution

  • Visits on the same day/service code must be billed on same invoice

Additional steps may be required if visits are exported or paid.

Option 1 - Merge Invoice

  1. Go to Billing > Invoice Search > By Visit.

  2. Use the search filters to locate the visit(s) in question.

  3. Review the visit(s) to verify they were billed on the same day and have the same Service Code.

  4. Once confirmed, select the applicable visit(s) checkbox(es) and click the Merge Invoices button.

Option 2 - Delete Invoice

  1. Go to Billing > Invoice Search > By Invoice.

  2. Use the search filters to locate the invoice in question.

  3. In the invoice, review visits to verify that the agency billed the invoice on the same day and has the same Service Code.

  4. To remove visits from the invoice, click theDelete icon.

  5. Click the Patient Name link to route to the Patient Calendar. In the calendar, select the visit to access the visit window.

  1. Edit the Service Code in the Visit window.

  2. Click Save.

  • Visit should NOT be placed on Manual Hold

  1. Go to Billing > Invoice Search > By Visit.

  2. Use the search filters to locate the invoice in question.

  3. Click theY link in the E-Billing Manual Hold column.

  4. Select Single Claim from the options.

  5. Click OK.

  • Does NOT meet POC Compliance Requirements

  1. Review the Contract Required Compliance rules.

  2. Click the Edit icon ( ) to open the visit window and select the Visit Info tab.

  3. Manually enter the Duties to satisfy the required compliance rule.

  4. Click Save.

Problem

Resolution

  • Review Contract Start Date and Alt Patient Number

  • Missing Contract Start Date

  • Discharge Date Elapsed

  1. Go to Patient > Search Patient. Search for the patient and click to open. 

  2. Under Contract review the Alt Patient ID. Click the Edit link and enter the Alt Patient ID in the text window. Contact the payer if the field is unavailable to edit.

  3. Click the Update link.

  4. Review the Service Start Date. Click the Date link to edit in the pop-up window.

  5. Click Save.

  • DX Code May Fail Specificity Guidelines (if configured to validate for Flag 10 ICD Codes)

  1. Go to Patient > Search Patient. Search for the patient and click to open.

  2. Under Authorizations/Orders click theEdit link.

  3. Click the Add button in the Billing Diagnosis Code(s) section.

  4. Click the ? beside the ICD field to search for the diagnosis code in the Authorization Default DX Code.

  5. Click the most specific ICD code that applies to the patient.

  6. Click Save to apply the ICD Code to the authorization.