Claim Status Report (By Claim)

  • Updated

The Claim Status Report (By Claim) is similar to the Claim Status Report (By Service Date) except that the line item detail includes the number of units for each service rather than defaulting to one unit per row. Users will be able to select the same column options as in the Claim Status Report By Service Date.

The Claim Status Report offers the most customization within AveaOffice and can be used in a multitude of ways. A strong user will have various templates of reports created that are run at a cadence to gather certain information.

Accessing the Report

The Claim Status by Service Date report is available to be run at the Organization and Managing Organization levels. Let's review how to access this report.

  1. Open the Reporting section.
  2. This Report is available at both the Organization and Managing Organization levels.
    • Organization: Running the report from the Organization level allows the user to select one or more Practices under an Organization and will include all facilities under the selected Practices.
    • Managing Organization: Running the report from the Managing Organization level allows the user to select one or more Organizations and will include all Practices and Facilities under the selected Organizations. 
      • Report data will run in the background and be sent to the requesting user by secure e-mail from reports@aveasolutions.com. A CSV file is sent via Protected Trust to download and open in Excel or another desktop app.
  3. Under Billing Reports, select Claim Status Report (By Claim).

Creating the Report

Let's review how to run this report.

Report Options

  • Date Type: Select either Service Date Start, Submission Date Start, Follow Up Date, or Closed Date as the date range to run the report by.

  • Start and End Date: The dates selected will return service dates for active treatment episodes within the requested date range.

  • Claim State: Filter the report prior to downloading by the A/R Claim State of Closed, Discontinued, Open, or Voided.

  • Patient Name Filter: Type in the patient's full name to display line items only pertaining to that patient.)

  • A/R Classification Filter: Choose to display only Insurance, Mixed Insurance, or Private Pay patients. 

Report Columns

Use the Report Columns selector to choose which columns should be included in this report.

  • To add columns: Use the checkboxes to select one or more data points on the Available side. They will automatically appear on the Selected side.
  • To remove columns: Uncheck the selected checkbox on the Available side. 
  • To reorder columns: On the Selected side, click on the desired data point and drag and drop the column into the desired position. 

The following report column options are available for selection:

Column

Description

A/R Classification

The A/R Classification chosen on the treatment episode. This can either be Insurance, Private Pay, or Mixed Insurance/Private Pay. Found on Patient > Treatment Episode > Intake > Admit/Discharge

Additional Patient Responsibility

This is the total amount of PR 45 code amounts on the payment(s)

Adjustment Group Code

This displays all group codes for payments made against the claim

Adjustment Reason Code

This displays all adjustment reason codes for payments made against the claim

Adjustment Reason Code Amount

This will display all adjustment reason code amounts for payments made against the claim

Admit Date

The date the patient was admitted for this treatment episode

Admitting Diagnosis Code

The ICD-10 diagnosis code set as the patient's admitting diagnosis code in the treatment episode

Assigned User

Assigned user to the claim

Authorization Number

Authorization number of the claim from the respective U/R plan for the dates of service

Authorization Status

The Authorization Status set on the utilization plan for the claim. This is either Authorized, Denied, Pending, Not Required, or Required - Not Obtained

Benefits Assignment

View the assignment of benefits to determine if the payment needs to be collected directly from the patient. Will display as Facility or Patient based on the value set under Patient > Treatment Episode > Intake > Insurance > Insurance Set > Policy Holder > Benefits Assignment

Billing Account Number

The AveaOffice assigned Treatment Episode Number. This can be found in Patient > Treatment Episodes

Charges

Amount charged

Check Number

Number displayed on the payment collection

Claim ID

AveaOffice or Legacy claim number

Claim Issues

The most recent issue source and type chosen for the resubmission or correction for the claim

Claim Payer(s)

Name of the payer associated with the payment

Claim Queue 

The current Claim Queue associated with a claim. This is part of a customized workflow used in the claim lifecycle.

This can be found in Patient > Treatment Episode > Insurance Billing or Patient > Treatment Episode > Insurance Billing > Claim > Workflow

Claim State

The A/R claim state. This is either Open, Closed, Voided, or Discontinued. Both open and closed claims will show on the report. Open means that the claim is still on the Accounts Receivable (A/R) Report. Closed means that the claim is no longer on the A/R Report.

Claim Status

The current Claim Status associated with the claim. This is part of a customized workflow used in the claim lifecycle.

This can be found in Patient > Treatment Episode > Insurance Billing or Patient > Treatment Episode > Insurance Billing > Claim > Workflow.

Claim Type

Institutional or Professional
Closed Date The date the claim was closed

Client Name

 Name of the patient

Co-Insurance

Amount associated with a PR 2 in the claim payment

Co-Pay

Amount associated with a PR 3 in the claim payment

Covered

Calculated as the sum of the (Deductible + Co-Insurance + Co-Pay + Paid to Facility + Paid to Patient)

Date of Birth

Patient's DOB

Date(s) Paid

Payment Date listed on the payment collection

Dates(s) Payments(s) Deposited

Deposit Date entered on the payment collection

 

Date(s) Payment(s) Posted

Post Date listed on the payment collection

Days Outstanding

Number of days since the claim was submitted from AveaOffice

Days to Close 

Number of days the claim was open before being assigned a Closed state

Deductible

Amount associated with PR 1 in the claim payment 

Difference Covered vs. Expected

Calculated as the Expected Amount minus the Covered Amount. Expected Amount is entered per unit of service in the Payer's profile under Practice Admin. 

The expected rate defaults to the full charge amount if Payer Rates have not been set in Practice Admin > Payers.

Discharge Date Date listed as the discharged date for the patient's Treatment Episode under which the claim was billed
DOS End

The start date of the billable

DOS Start

The end date of the billable

Expected Amount

This is the amount that the provider can anticipate being covered by the payer. This number is determined by what has been entered under Payer Rates in the Practice. If there are no payer rates set for this payer and service, then this number will default to the total billed charges of the claim. This field was previously called Amt Allowed Expected. This is calculated as Expected Unit Rate x Number of Units. 

  • When no payer rate is entered, then it is calculated as the (Facility Service Rate x Number of Units). 
  • When a Service Rate is entered at the Patient Level (ex. single case agreement), the Expected Amount will be reported as the amount entered for the patient's service rate. In other words, the patient's service rate will override the payer profile and facility rates in the report.
Expected vs. Paid

This column shows the difference between what was expected versus what the insurance company actually paid. Calculated as the Expected Amount - Paid to Facility amount.

Facility Name of the facility under which the claim was billed
Follow Up Date The follow up date of the claim
Group Number The Group Number of the patient's insurance policy

Has Single-Case Agreement 

Whether the patient has a per service case agreement entered. This can be found under Patient > Treatment Episode > Scheduling and Utilization > Services Rates

HCPCS Code

Procedure code billed on the claim, if any.

Home Plan Payer

Payer listed in the Home Plan carve-out of the patient's insurance set

Insurance Balance

Calculation of the (ChargeAmount - PaidToFacilityAmount - Deductible - CoInsurance - All Adjustments except OA and CO-45)

Last Action Date

Date the most recent action was taken on a claim

Medical Record Number

The patient's Medical Record Number (associated with the Kipu EMR for integrated clients)

Network Type

Displays as In-Network if a payer rate was applied for this service or Out-of-Network if no payer rate is present for the service.

Original Claim Source

This will display AveaOffice if the claim originated from Avea or Legacy if the claim was imported from a previous system.

Other Diagnosis Codes

Any additional ICD 10 diagnosis codes add to the patient's Behavioral or Standalone Service diagnosis codes in the treatment episode that are not Admitting or Principal.

Paid Amounts

Sum of Paid to Facility + Interest + Paid to Patient amounts

Paid to Facility

Amount paid to facility as listed on the payment

Paid to Patient

Amount paid to the patient as adjusted by code PR or OA 100 on the payment

Patient Adjustments

This displays the provider adjustment amount applied to the billable created from the claim

Patient Balance

Calculated for Closed claims as the sum of (Paid-to-Patient Deductible + Co-Insurance + Co-Pay + Additional Patient Responsibility + any other PR reason code)

Patient ID

Internal ID number entered for the patient's profile

Patient Name

The name of the patient who received the treatment

Patient Payments

This will display any patient payments that have been applied to the billable created from the claim

Patient Share

Calculated for Open claims, as the sum of (Paid-to-Patient + Deductible + Co-Insurance + Co-Pay + Additional Patient Responsibility)

Payment Source

The payment source entered on the payment collection/check. This can either be Electronic, Paper, Payer Portal, Payer Representative, Client Data Import, or Manual

Payment Type 

The Payment Type is either ACH, Check, Insurance Credit Card, Non-Payment, or Reversal
Practice

Name of the Practice under which the claim was billed

Primary Payer Name of the primary payer to which the claim was submitted
Primary Payer Claim ICN Internal Control Number assigned to the claim or payment by the primary payer
Principal Diagnosis Code The ICD-10 diagnosis code set as the patient's principal diagnosis code in the treatment episode
Rendering Provider The attending physician listed on the claim
Revenue Code Revenue code associated with the service as it was submitted on the claim
Service The name of the service billed
Service Billing Profile Service billing profile used to generate the claim
Single Case Agreement ($) If a Single Case Agreement is present for the claim, the unit rate will be displayed, otherwise, this field will be blank. 

Submitted Date

Date the claim instance was submitted to the clearinghouse for processing
Subscriber ID Subscriber's member ID number as submitted on the claim. This can be found under Patient > Treatment Episode > Intake > Insurance > Payer Name > Policy Holder
Total Balance Sum of the Insurance Balance + Patient Balance columns
Units Total number of units of a service submitted on the claim

Results

The Claim Status Report (By Claim) downloads as an Excel file and produces a table where each row represents a claim service and each column contains a different piece of information about that claim. If one claim is billed with different services there will be different rows for the same claim listing the number of units rendered for each service.

When the report is run with the default columns selected, the columns are Patient Name, Service Date, Service, Claim State, Claim ID, Submitted Date, Claim Payer(s), Date(s) Paid, Paid Amounts, Units, Charges, Expected Amount, Paid to Facility, Patient Share, Difference Covered vs. Expected.

Save a Template

If you'd like to save a custom reporting configuration, click the Save icon. Next time you want to run this report, you can select the saved template from the Report Template drop-down. Click here to learn more about Report Templates.  

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