Changes are needed for a subset of claims grouped under an existing billing profile. To resolve, create a new billing profile so the necessary changes only impact the subset group of claim, instead of all 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 of the out-of-network payer.
Do No Use: 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.
Create a New Billing Profile
Let's review the steps for creating a new billing profile to apply to a specific subset of claims and updating the UR plan for the impacted patients to use the new billing profile.
- Navigate to the patient’s Treatment Episode and open the Scheduling and Utilization tab.
- From the UR tab, locate the UR plan used to submit the claim.
- Tip: If it is not clear which UR plan will correct the claims, click edit to the right of the potential UR plan.
- All associated claims are listed under the warning at the top.
- Note the Service and Service Billing Profile selected on the UR plan.
- Navigate to Practice Admin.
Note: Only Admin users can access this tab. Contact one of your account admins to make the needed edits if this tab is not visible.
- Open the Services tab and locate the service from the UR plan.
- Click on the Service and open the Billing Profiles tab.
- Click Create Service Billing Profile and set the Facility Rate for the new Service/Profile combination. See the Facility Rates section of this article.
- Navigate to the patient's Treatment Episode > Scheduling and Utilization > UR tab.
- Click Edit next to the UR plan used to submit the claim.
- Under Service Billing Profile. Choose the newly created Billing Profile from the drop-down menu.
- Save the Utilization Plan.
- Navigate to the patient’s Insurance Billing tab and open the Review Corrections tab.
- Click Check for Corrections and click Submit.
- Once corrections populate, click Compare to view changes. Click here for more information on comparing claim versions.
- Click Resolve to create a corrected claim.
- Complete the Select Correction Action form as described in the Claim Corrections and Rejections article.
- Once the corrected claim is created, send it to the payer from the Submit Claims tab in the Work Center > Insurance Claims.
- If the desired corrections do not appear, refer to the Corrections Troubleshooting article.