Common Claim Corrections: Changes to Claim Configuration

The system is designed to automate actions whenever possible to streamline the billing process. Before correcting a claim, it is important to know where the correction fits into these system automations and how the correction may impact other claims. To do this, users should be familiar with areas of the system that dictate claim configuration. This includes Practice Admin, Attendance, Claim Rules, and the Scheduling and Utilization Tab.

Equally important, is validating the need for a correction. There’s nothing more frustrating than sending a corrected claim only to find out that a correction was not necessary. Ensure that this does not happen by referencing any EOBs and reviewing how similar claims have been processed. When corrections are necessary, evaluate the impact on other claims. Doing this will save time and reduce the number of corrected claims going forward.

Consider asking some of the following questions:

• Is the change something that needs to be implemented across the board? To certain payers? Under certain conditions?
• Is it something variable that will change with every billing?
• Is the change necessary?
• Is there a denial in writing? Does that denial support the correction being made or refute it?
• Have other claims processed when billed in the same way?

Important: We recommend confirming that there isn't an existing service or billing profile that fits your needs before creating a new one. Billing Profiles and Services cannot be deleted, only deactivated. Creating extraneous services and billing profiles will complicate the billing process.

Common Claim Corrections

The type of corrections and how the corrections should be made will differ depending on whether the service that needs to be corrected is a UR Required or a Standalone service.

Use the following articles to help make claim corrections. Each article is designed to address a different correction situation. When deciding which section is appropriate, there are three essential questions to ask.

1. How was the service billed?
   1. Is the service UR Required or Standalone?
   2. Which billing profile was used to submit the claim?
      1. Billing profiles are manually selected for UR-required services. For standalone services, a claim rule will need to be created to select a non-default billing profile.
   3. Are there claim rules impacting the claim?
2. What is the scope?
   1. Is there a group, subset, or date range of claims that will or should be impacted by the corrections?
3. Should the corrections be automatically triggered by set conditions, or selected on an as-needed basis?

Claim Correction Processes 

Correction Type	When to use	When not to use
UR Required Services: Changes to the Existing Billing Profile	Changes are needed for a group of claims submitted under the same billing profile. Reference this article if the changes should impact all claims submitted using the profile in question. Example: A billing profile is only used to submit claims to BCBS and the changes are needed for BCBS claims.	Don't use this change if the changes are only appropriate for a subset of the claims submitted using the billing profile. Example: The default profile is used for all payers, but changes are only needed for UMR and UHC.
UR Required Services: Creating a New Billing Profile	Changes are needed for a subset of claims not grouped under any existing billing profile. Create a new billing profile if the changes needed should not impact the group of claims submitted with the current billing profile. Example: A single billing profile is used for all out-of-network payers but the changes being made should only impact one payer.	Don't use this change if a billing profile already exists for the group of claims. Example: Changes are needed for Aetna claims going forward and a billing profile already exists that is used exclusively for Aetna claims.
UR Required Services: Changes to the UR Plan	Options already exist for the necessary changes, but the UR plan does not have the correct option selected. UR Required Services can be corrected from the UR plan when changes are needed for Facility, Service, Service Billing Profile, Rendering Provider, Billing Provider, Authorized Status, or Authorization Number. Note: Changes made to a UR plan will impact all claims billed out for that client using that UR plan. Example: The practice was chosen as the billing provider, but the service was truly billed by the rendering provider.	-
Standalone Services: Changes to the Existing Billing Profile	Changes are needed for a group of claims submitted under the same billing profile. Make changes to an existing Billing Profile if the changes should impact claims submitted using the profile in question. Example: A billing profile is only used to submit claims to BCBS and the changes are needed for BCBS claims.	Don't use if the changes needed are only appropriate for some of the claims submitted using the billing profile. Example: The default profile is used for all payers, but changes are only needed for UMR and UHC.
Standalone Services: Creating a New Service for As-Needed Changes	Changes are needed on a case-by-case basis; there are no specified conditions that should prompt the changes. Standalone services do not have the option to manually select a billing profile in the claim creation process. Creating separate services allows users to choose between options in the attendance calendar. To make as-needed changes, create a new standalone service. Example: Itemization is sometimes needed for a service but there are no specified conditions that would prompt this.	Don't use this method if there are conditions that should prompt the changes or if this is a U/R Required service. Example: Itemization is needed for Cigna claims. In this example, a claim rule to set a billing profile would be more appropriate.
Standalone Services: Changes in the Attendance Calendar	Standalone services can be corrected without creating a new service or setting a claim rule if the desired changes are to: Facility, Rendering Provider, Referring Rendering Provider, Referring Rendering Provider Role, Service, Billing Provider, Diagnoses, or Present on Admission Indicator.	-
Conditional Changes: Claim Rules	Use this option if there are conditions that should always trigger certain claim settings. For standalone services, claim rules are the only way to select the non-default billing profile. Standalone services do not have the option to manually select a billing profile in the claim creation process. Instead, they require claim rules to select non-default billing profiles. Regardless of claim type, claim rules are appropriate if there are fixed conditions that should trigger changes.	-