Claim Issues: Source and Type

Claim Issues are added to claims to further specify what is preventing the claim from being processed. Issues are created with two variables, the issue Source (like the payer, practice, etc) and the issue Type. These issues can then be reported on, allowing management to understand the types of issues the organization is running into and provide an opportunity to solve problems. Issues are used in conjunction with claim status and queues. 

Issues Video

Claim Issue Sources

A claim issue source is a category that describes the root cause of the issue when there is a problem with a claim. Each Claim Issue Type is tied to a Claim Issue Source.

Some examples include:

Name	Definition	Example
Billing	There was a mistake during the billing of the claim.	Billing dates of service that the patient never attended.
Patient	Information or documentation is needed from the patient.	COB information needs to be updated with the payer.
Payer	The issue lies with the payer.	The payer's system read the claim file incorrectly and needs to be reprocessed.
Practice	Information or documentation is needed from the practice.	Medical records have been requested and the provider needs to send them to the billing team.
U/R	There was an issue with the pre-authorization process.	The incorrect authorization number was entered into AveaOffice.
VOB	There was an issue during the initial VOB process.	The patient's coverage termed and that information wasn't discovered during the VOB process.

Create a New Issue Source

To create a new issue source:

1. Navigate to Managing Organization Admin > Configuration > Claim Issue Sources.
2. Click Create Claim Issue Source.
   
3. Type in the name of the issue source and click Create.

Claim Issue Types 

Claim issue types are used to further specify what is preventing the claim from being processed.

Some examples include:

• EOB Requested (Payer): Tagging a claim with this issue type lets the user know the reason this claim is still outstanding. The EOB was requested from the payer, and the team is having issues receiving it from the payer in a timely manner.
• Incorrect Authorization Number: This tag will help identify data entry issues when authorization numbers are being entered into the utilization plans. 
• Incorrect Electronic Payer Set for Patient: This tag can help identify claims that were initially sent to the incorrect payer. Identifying these types of claims will help identify gaps in the VOB process.
• Medical Records Under Review: Claims that are tagged with this issue can help identify a waiting period when the payer is reviewing the medical records that were sent in.
• No OON Coverage: Tagging a claim with this issue will highlight specific questions that the team can start asking during the VOB process. If this issue keeps coming up, the manager will know there are improvements to be made with the VOB calling process.
• NPI/Tax ID Not Registered with Payer: Tagging claims with this issue will help to identify the claims that aren't able to process because the provider is not on file with the payer. If the credentialing is assigned to a specific individual, they can reprocess all claims with this tag once the credentialing is complete.
  • Recommendation: Use the Issue queue with these claims. A biller will be able to filter by the Issue queue when looking at overdue claims to see the list of claims that need to be resubmitted once the issue is resolved.

Create a New Issue Source

To create a new issue type, navigate to Managing Organization Admin > Configuration > Claim Issue Types.

1. Click Create Claim Issue Type.
2. Fill out the Name and select the issue Source.
   
3. Click Create.