This process allows for posting payment information
from payer remittances (ANSI 835) to billed claims in
the data based.
Payment information is matched to billed claims on a
number of elements including facility, patient number,
service dates, billed charges and date the claim was
billed. Where a match occurs, the ANSI 835 data segment
and an EOB based on that segment are attached to the
billed claim. Both the 835 segment and the EOB are available
to view or print.
When a payment matches a billed claim the system determines
if a secondary payer claim must be created. A secondary
claim is created when the primary payer reduced their
payment by a deductible, coinsurance or other copay,
the payer
did not automatically cross their payment to the next
payer, and a secondary payer is on the claim.
When a secondary payer claim is required, a copy of the
original claim is made active, updated with the payment
information including amounts paid, dates paid, payer
ICN, and appropriate value codes. The new active claim
is subjected to Claim Agent’s payer specific edits.
Like any active claim, modifications to the claim may
be made by the user.
Claim Agent allows the user to determine if a secondary
payer may be billed electronically or must be paper billed.
This determination of billing route allows for electronic
billing to electronically capable second payers and printing
of paper claim forms and EOB for paper only secondary
payers.
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