Corrections Overview and Troubleshooting

The system is designed to automate actions whenever possible, streamlining the billing process. Before correcting a claim, it is essential to understand where the correction fits within these system automations and how it may affect other claims. To do this, Users should be familiar with areas of the system that dictate claim configuration. These areas include Practice Admin, Attendance, Claim Rules, and the Scheduling and Utilization Tab.

Determine What Changes Are Needed

The type and method of corrections will differ depending on whether the service is a U/R-required or a Standalone service. When deciding which correction is appropriate, ask yourself three essential questions and use the decision tree below to determine the best course of action.

• 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?
• Is there a group, subset, or date range of claims that will or should be impacted by the corrections?
• Should the corrections be automatically triggered by set conditions, or selected on an as-needed basis?

Correction Generating Processes

Validate the need for a correction by reviewing EOBs and similar claim processing. When corrections are needed, assess their impact and follow the workflows below. This prevents unnecessary corrections, saves time, and minimizes future errors.

Important: We recommend confirming that there is no existing service or billing profile that meets your needs before creating a new one. Billing Profiles and Services cannot be deleted, only deactivated. Creating extraneous services and billing profiles can complicate the billing process.

• • Use this process when changes are needed for a group of claims submitted under the same billing profile. This process will affect all claims using the billing profile and should not be used when the billing profile needs to change based on a specific payer's conditions.
  • Use this process when changes are needed for a subset of claims not grouped under any existing billing profile. This process should be used if a payer has specific, service-related billing requirements that differ from those of other payers.
  • Use this process when changes are needed to the billing profile or U/R plan for a subset of claims for one patient. It is important to note that corrections will be generated for every claim associated with the U/R plan.

    U/R required services can be corrected from the U/R plan when changes are needed for:

    • Facility
    • Service
    • Service Billing Profile
    • Rendering Provider
    • Billing Provider
    • Authorized Status
    • Authorization Number
• • Use the following process to generate corrections when any of the following items need to be corrected on a claim:
    • Facility
    • Rendering Provider
    • Referring Rendering Provider
    • Referring Rendering Provider Role
    • Service
    • Billing Provider
    • Diagnoses
    • Present on Admission Indicator
  • Use steps 7-17 of this process when changes are needed to a group of claims submitted under the same billing profile. This process will affect all claims using the billing profile and should not be used when the billing profile needs to change based on specific payer's conditions.
  • Use this process when changes are needed on a case-by-case basis when there are no specified changes that should prompt the changes.
  • Refer to this services overview for information on the three-step process of creating new services in the RCM. Since users are unable to select a billing profile when creating a standalone service, creating an additional service provides more options for a biller when requirements vary by payer. If a new service needs to be recorded due to a correction, refer to the workflow below.
    • 1. To start, create a voided claim using the process outlined in this article.
      2. After creating the claims in the Work Center, use the Mark as Submitted process. This will make the voids in the system, but not submit them directly to the payer.
      3. Next, record the new service as desired using the processes outlined here.
      4. Repeat step #2 to create the new claims in the RCM but not submit them to the payer.
      5. After marking the new claims as submitted, navigate to the patient's profile and click the Claims quick link.
         
      6. Locate the claim(s) with the newly created service recorded that you'd like to submit to the payer and click Resubmit.
         
      7. Input the Internal Control Number (ICN) from the voided claim. This information can be found in the Work Claim screen.
         
      8. Once the ICN has been input, add any additional information before selecting a Resubmission Issue.
         
      9. Finally, click Submit to create the resubmission and follow the submission process.
         
• • Dates of service cannot be added to a claim, only removed. Use the processes outlined below to separate services from a claim.
    

    Split a Claim:

    1. Unsubmit the dates of service you wish to remove from the existing claim.
    2. Create and submit a correction for the existing claim.
    3. Navigate back to the Attendance Calendar and resubmit the remaining dates of service.
    4. Follow the new claim creation process and submission process. 

    Permanently Remove Dates from a Claim:

    1. Unsubmit the dates of service you wish to remove from the existing claim.
    2. Create and submit a correction for the existing claim.
    3. Navigate back to the Attendance Calendar and delete the remaining service dates.
  • Some payers may require a claim to include a bill-type suffix/resubmission code of 7, even if no changes are needed in the configuration. When this occurs, a claim form rule is available to update both the bill-type suffix and the resubmission code.
  • Use this process if a claim rule is available to change the desired box by setting specific conditions that trigger the correction(s). For example, since standalone services utilize a default billing profile, a service grouping rule should be created to update the billing profile on a standalone claim with specific conditions set to ensure the claim triggers appropriately.

Troubleshooting Steps

Users may encounter issues with corrections not generating or flagging claims for corrections that were not desired. Refer to the below troubleshooting steps to help identify the root cause of the issue.

Note: If you are unable to determine why corrections are/are not generating, please reach out to our support team at [e-mail].

• 1. Check the Corrections History for corrections that were ignored previously.
     • This is where corrections go when the Ignore radio button is selected on the Select Correction Action form.
     • You can View and Update corrections from this tab.
  2. Check the patient's other Treatment Episodes. If the patient has multiple treatment episodes, the corrections may be in a different episode than the one you're currently viewing.
  3. Ensure that changes were made to the correct practice or all applicable practices.
     • Example: Detox billing profiles were edited under ABC Treatment Center, but the same changes were not made under 123 Treatment Center.
  4. Ensure that the claim is associated with the edited UR plan or attendance record.
     • Example: Edits were made for the UR plan from 4/10/18 to 4/15/18, but the claim is associated with the 4/16 to 4/20/18 UR plan.
  5. Ensure that Effective Dates and Scheduled Change Sets encompass the dates of service on the claim.
     • Example: If a claim rule has a scheduled change set to become active on 2/15/23 and the claim has a date of service of 2/10/23. The claim rule will not impact the claim. Backdate the rule so it is active on or before the date of service on the claim.
  6. Pay attention to similarly named Services and Billing Profiles.
     • Example: Changes were made to the service, Family Therapy w/out Patient but the service on the claim is Family Therapy w/ Patient. Corrections would not prompt for the service, because no changes were made to the service.
  7. Ensure that the service rate is referenced in the Facility in Practice Admin > Facilities.
  8. If the service needs to be presented as a professional, ensure there is a Professional Service Line and a Professional Unit Rate.
  9. Check the Claim Rules. If there are conflicting changes, claim rules will override other settings.
     • Example: The service billing profile in the patient’s U/R tab indicates that the claim should be sent out as professional. There is a claim rule to set the claim type to Institutional. The claim rule will take precedence and the claim will go out as institutional.
  10. If using claim rules, ensure that all conditions are met by the claim that needs corrections.