Versions Compared

Version Old Version 2 New Version 3
Changes made by

vickyp

vickyp

Saved on

Key

  • This line was added.
  • This line was removed.
  • Formatting was changed.

This report shows mapping between claims and remittance advices. Report contains shows all claims submitted by providers. Some claims will have Remittance Advices, the other claims will not have them. However, all claims present in this report.

Claim Reconciliation Report

...

the provider no matter whether they have payer replies (corresponding Remittance.Advice transactions) or not.

Claims Reconciliation Report

The report contains only one worksheet: Reconciliation Summary Report. Data aggregation is performed on a claim level.

Data in the worksheet is sorted by:

  1. Sender ID
  2. Claim ID
  3. Submission Date.

Table below describes columns presented on this worksheet.


Column
CS Field
Description
First CS DateHeader.TransactionDateTransaction date and time of the first Claim.Submission transaction.
Last CS DateHeader.TransactionDateTransaction date and time of the latest Claim.Submission transaction where a claim is either correction or internal complaint. If a claim has no resubmission, then it equals First CS Date.
First RA DateHeader.TransactionDateTransaction date and time of the first Remittance.Advice transaction.
Last RA DateHeader.TransactionDateTransaction date and time of the latest Remittance.Advice transaction.
Claim IDClaim.IDUnique identifier assigned to a claim by the provider.
Claim ID PayerClaim.IDPayerUnique identifier assigned to a claim by the payer.
Pt Visit DateEncounter.Start
Pt Visit Date TimeEncounter.Start
Sender IDHeader.SenderIDLicense number of a facility that is the sender of Claim.Submission transaction.
Reciever IDHeader.ReceiverIDLicense number of an insurance company or TPA that is the receiver of Claim.Submission transaction.
Payer IDClaim.PayerIDLicense number of an insurance company that is the payer of a claim.
Provider IDClaim.ProviderIDLicense number of the provider.
Member IDClaim.MemberIDInsurance card number of the patient.
MRNEncounter.PatientIDPatient Medical Record Number assigned by the provider.
Original Claimed AmountActivity.Net
Current Claimed AmountActivity.Net
Patient ShareActivity.PatientShare
Pending Amount

Original Paid AmountActivity.PaymentAmount
Paid AmountActivity.PaymentAmountAmount paid by the payer for a claim.
Denied Amount

Write Off Amount
Write Off Amount as per the latest Write Off Report.
Final Denied Amount

Denied Clearing Error

Processed Amount

Principal DiagnosisDiagnosis.CodePrincipal diagnosis code. 
Diagnosis Text
Principal diagnosis description.
Secondary Diagnosis 1...NDiagnosis.CodeSecondary diagnosis code. This value is taken from diagnosis that has Diagnosis.Type <> Principal.
Diagnosis Text
Secondary diagnosis description.
Payment Status

Paid — a claim is fully paid (Paid Amount >= Processed Amount);
Partly Paid — a claim is partly paid (Paid Amount < Processed Amount);
Denied — a claim is fully denied (Paid Amount = 0);
In Process — remittance advice is not received for the claim:

  • a new claim is submitted and no remittance advice is yet received;
  • a claim resubmission (correction or internal complaint) is submitted and no remittance advice is yet received; in this case Paid Amount may have value from previous claim submissions;

Written Off — a claim is written off using /wiki/spaces/RES/pages/75961340Write Off Registration.

Claim Status
Original — if this is the initial claim submission;
Resubmission 1 — if this is the first claim resubmission;
Resubmission N — if this is N claim resubmission.
Missed Take Back

...




Activities Reconciliation Report

Table below describes columns in the report.

The report contains only one worksheet: Reconciliation Summary Report. Data aggregation is performed on an activity level.

Table below describes columns in the report.

ColumnTransaction FieldDescription
First CS DateHeader.TransactionDateTransaction date and time of the first Claim.Submission transaction.
Last CS DateHeader.TransactionDateTransaction date and time of the latest Claim.Submission transaction where a claim is either correction or internal complaint. If a claim has no resubmission, then it equals First CS Date.
First RA DateHeader.TransactionDateTransaction date and time of the first Remittance.Advice transaction.
Last RA DateHeader.TransactionDateTransaction date and time of the latest Remittance.Advice transaction.
Rx NumberObservation.ValueRx Number; value is taken for observation with  Observation.Code = Prescription No.
Fill CounterObservation.ValueFill Counter; value is taken for observation with  Observation.Code = Refills or Fill Counter.
CodeActivity.CodeActivity code specified by activity type.
Type
Activity type.
Description
Activity code description.
Claim IDClaim.IDUnique identifier assigned to a claim by the provider.
Claim ID PayerClaim.IDPayerUnique identifier assigned to a claim by the payer.
Activity IDActivity.IDUnique identifier of an activity within a claim.
Auth. NumberActivity.PriorAuthorizationIDPrior authorization number.
Auth. Approval Date
Authorization approval date. Always N/A until future versions.
Service DateActivity.StartDate of the provided service.
Service Date TimeActivity.StartDate and time of the provided service.
Ord. Clinician LicenseActivity.OrderingClinicianLicense number of the clinician who ordered an activity or referred the patient for an activity.
Ord. Clinician Name
Full name of the clinician who ordered an activity or referred the patient for an activity.
Disp. Clinician LicenseActivity.ClinicianLicense number of the clinician who provided an activity (treatment or care) for the patient.
Disp. Clinician Name
Full name of the clinician who provided an activity (treatment or care) for the patient..
Sender IDHeader.SenderIDLicense number of a facility that is the sender of Claim.Submission transaction.
Receiver IDHeader.ReceiverIDLicense number of an insurance company or TPA that is the receiver of Claim.Submission transaction.
Payer IDClaim.PayerIDLicense number of an insurance company that is the payer of a claim.
Provider IDClaim.ProviderIDLicense number of the provider.
Member IDClaim.MemberIDInsurance card number of the patient.
MRNEncounter.PatientIDPatient Medical Record Number assigned by the provider.
Sales Price
Sales price for the drug. It has value only if Activity.Type = 5.
QuantityActivity.QuantityDispensed quantity (number of units) for an activity.
Original Claimed AmountActivity.NetNet amount for an activity from the first Claim.Submission transaction.
Current Claimed AmountActivity.NetNet amount for an activity from the latest Claim.Submission transaction.
Patient ShareActivity.PatientShareAny fee that the payer is expecting the provider to collect from the patient.
Pending Amount

Pending Amount is shown as described in the logic above.

Original Paid AmountActivity.PaymentAmountPaid Amount is sum of all Remittance Advices for this claim.
Paid AmountActivity.PaymentAmountAmount paid by the payer for an activity.
Missed Take Back

Logic to calculate this value is described in section 74716133.

Default value for this column is Noclaim.
Paid AmountActivity.PaymentAmountAmount paid by the payer for an activity.
Missed Take Back
  1. Show paid amount only for the last remittance advice if all conditions below are true:
    1. Last claim resubmission is correction.
    2. There is no remittance advice with TKBK-001 or TKBK-002 for current claim cycle (claim submission + remittance advice).
    3. Previous claim cycle (claim submission + remittance advice) has Paid Amount > 0.
  2. Set value Yes for column Missed Take Back if above conditions are met. Otherwise set value No.
Denied Amount

Amount denied by the payer for an activity. Calculated as Current Claimed Amount – Total Paid Amount.

Write Off Amount
Write Off Amount as per latest /wiki/spaces/RES/pages/75961340the latest Write Off Report.
Write Off Date
Date when the amount is written off as per latest /wiki/spaces/RES/pages/75961340.Final Denied AmountCalculates as Denied Amount – Write Off Amount.Denied Clearing ErrorLogic to calculate this value is described in seciton Clearing Errors in Remittance.Advicethe latest Write Off Report.
Final Denied Amount
Amount denied by the payer for an activity. Calculates as Denied Amount – Write Off Amount.
Denied Clearing Error

In case -0.50 <= Denied Amount < 0.00:

  1. Denied Clearing Error = Denied Amount, and
  2. Denied Amount = 0.00.

Otherwise the column is empty.

Processed Amount
Calculates as Paid Amount + Denied Amount.
Denial CodeActivity.DenialCodeDenial code for a rejected activity.
Denial Reason
Denial code description.
Principal DiagnosisDiagnosis.CodePrincipal diagnosis code. 
Diagnosis Text
Principal diagnosis description.
Secondary Diagnosis 1...NDiagnosis.CodeSecondary diagnosis code. This value is taken from diagnosis that has Diagnosis.Type <> Principal.
Diagnosis Text
Secondary diagnosis description.
Payment Status

Paid — a claim is fully paid (Paid Amount >= Processed Amount);
Partly Paid — a claim is partly paid (Paid Amount < Processed Amount);
Denied — a claim is fully denied (Paid Amount = 0);
In Process — remittance advice is not received for the claim:

  • a new claim is submitted and no remittance advice is yet received;
  • a claim resubmission (correction or internal complaint) is submitted and no remittance advice is yet received; in this case Paid Amount may have value from previous claim submissions;

Written Off — a claim is written off using /wiki/spaces/RES/pages/75961340Write Off Registration.

Claim Status

Original — if this is the initial claim submission;
Resubmission 1 — if this is the first claim resubmission;
Resubmission N — if this is N claim resubmission.