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Table of Contents

Overview

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

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

  1. Only latest claims are taken into consideration. That means all data except Paid Amount is shown from the latest claim vrsion: diagnoses, denial code, claimed amount, etc.
  2. Claim duplicates are not reflected even if they are submitted by mistake.
  3. Remittance advice duplicates are not counted too.

Claims Reconciliation Report

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

Data in the worksheet

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is sorted by:

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

Table below describes columns presented on this worksheet.


Column
CS Transaction Field
Description
First CS DateHeader.TransactionDateTransaction date Transaction date and time of the first Claim.Submission transaction.
Last CS DateHeader.TransactionDateTransaction date Transaction 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 Transaction date and time of the first Remittance.Advice transaction.
Last RA DateHeader.TransactionDateTransaction date Transaction 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.StartEncounter start date.
Pt Visit Date TimeEncounter.StartEncounter start date and time.
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 AmountActivityClaim.NetNet amount billed by the provider to the payer for a claim in the first Claim.Submission transaction.
Current Claimed AmountActivityClaim.NetNet amount for a claim from the latest Claim.Submission transaction.
Patient ShareActivityClaim.PatientShareAny fee that the payer is expecting the provider to collect from the patient for a claim.
Pending Amount
Calculates as sum of Pending Amount for all activities in a claim.
Original Paid Amount
Activity.PaymentAmountAmount paid by the payer for a claim in the first Remittance.Advice transaction. Calculates as sum of Paid Amount for all activities in a claim.
Paid AmountActivity.PaymentAmount
Amount paid by the payer for Amount paid by the payer for a claim latest Remittance.Advice transaction. Calculates as sum of Paid Amount for all activities in a claim.
Denied Amount
Amount denied by the payer for a claim. Calculated as sum of (Current Claimed Amount – Paid Amount) for all activities in a claim.
Denied Write Off Amount
Write Off Amount as per the latest Write Off Report. Calculated as sum of Write Off Amount for all activities in a claim.
Final Denied Amount
Final amount denied by the payer for a claim. Calculated as sum of (Denied Amount – Write Off Amount) for all activities in a claim.
Denied Clearing Error

Calculates as sum of Denied Clearing Error for all activities in a claim.

Processed Amount
Net amount for a claim according to the latest Remittance.Advice transaction. Calculates as sum of (Paid Amount + Denied Amount) for all activities in a claim.
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

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Yes if the following conditions are met:

  • the latest claim resubmission is correction;
  • the previous claim cycle has Paid Amount > 0;
  • there is no remittance advice with TKBK-001 or TKBK-002 denial code for corresponding activities.

No otherwise.


Activities Reconciliation Report

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

Table below describes columns in the report.

ColumnTransaction FieldDescription
First CS DateHeader.TransactionDateTransaction date Transaction date and time of the first Claim.Submission transaction.
Last CS DateHeader.TransactionDateTransaction date Transaction 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 Transaction date and time of the first Remittance.Advice transaction.
Last RA DateHeader.TransactionDateTransaction date Transaction 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  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 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 a 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 for an activity.
Pending Amount

If the latest claim version does not have corresponding Remittance.Advice, then Pending Amount = Current Claimed Amount – Claimed Amount from the previous claim version.

  • It is negative if Current Claimed Amount < Claimed Amount.
  • Pending Amount
is shown as described in the logic above
  • = Claimed Amount if there is only initial claim submission without Remittance.Advice. 

Otherwise, if the latest claim version has corresponding Remittance.Advice, then Pending Amount = 0.00 to indicate that payer has processed the initial claim.

Original Paid AmountActivity.PaymentAmountPaid Amount is sum of all Remittance Advices for this claimAmount paid by the payer for an activity. Calculates as sum of Paid Amount in all related Remittance.Advice transactions for an activity (including those with TKBK-001 or TKBK-002 denial code).
Paid AmountActivity.PaymentAmountAmount

Corrected amount paid by the payer for an activity.

It equals Paid Amount only from the latest Remittance.

Missed Take Back

Logic to calculate this value is described in section 74716133.

Default value for this column is NoAdvice transaction if the following conditions are met:

  • the latest claim resubmission is correction;
  • the previous claim cycle has Paid Amount > 0;
  • there is no remittance advice with TKBK-001 or TKBK-002 denial code for corresponding activities.

Otherwise, it equals Original Paid Amount.

Denied Amount

Amount denied by the payer for an activity. Calculated  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/75961340the latest Write Off Report.
Final Denied Amount
Calculates Amount denied by the payer for an activity. Calculates as Denied Amount – Write Off Amount.
Denied Clearing ErrorLogic to calculate this value is described in seciton Clearing Errors in Remittance.Advice

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
Net amount for an activity processed by the payer. Calculates as Paid Amount + Denied Amount.
Denial CodeActivity.DenialCodeDenial code for a rejected activity. 
  1. Even if the latest Remittance.Advice transaction has Denial Code, it is not shown in the report if Paid Amount = Claimed Amount and Paid Amount <> 0.
  2. If the latest Remittance.Advice transaction has no Denial Code but Paid Amount <> Claimed Amount, then Denial Code is taken from the second to the latest remittance. If that has no Denial Report either, then Denial Code is taken from the previous remittance and so on.
  3. Take Back Denial Code is either TKBK-001 or TKBK-002.
  4. If an activity has a non-Take Back Denial Code and Take Back Denial Code, then a non-Take Back Denial Code is shown.
  5. If an activity has only a Take Back Denial Codes, then any of them is shown.
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.

Missed Take Back

Yes if the following conditions are met:

  • the latest claim resubmission is correction;
  • the previous claim cycle has Paid Amount > 0;
  • there is no remittance advice with TKBK-001 or TKBK-002 denial code for corresponding activities.

No otherwise.