PrognoCIS Help: Set Claim/s Status / Parameters

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Introduction : Using this popup, user can set Status/s or Parameter/s of Claim/s. On clicking the Set Claim Status option from the vertical ellipsis for a single Claim or by clicking the Set Claim/s Status / Parameters icon for multiple claims, Set Claim/s Status / Parameters popup is invoked. This popup displays the selected Claim Ids followed by radio buttons for selection. These include:

Mark Claim/s as Reviewed for Eligibility

Mark Claim/s as Reviewed for Coding

Fetch Pri/Sec Ins Eligibility for DOS

Mark Claim/s Ready To Send

Ignore Warning/s and Mark Claim/s Ready To Send

Claims Batch (Please Select the Batch)

On Hold (Please Select the Reason)

Their functionality has been explained below:

Mark Claim/s as Reviewed for Eligibility: Select the Mark Claim/s as Reviewed for Eligibility radio button and click on the OK button to mark Claim/s as Reviewed for Eligibility. The Eligibility Reviewed column on the Approve Claims screen displays the keyword 'Reviewed' for Claim/s that have been marked as reviewed for Eligibility. If Claim/s have not been marked as Reviewed for Eligibility then the Eligibility Reviewed column is shown blank.

Note:

Insurance and Self-Pay Claims can be marked as reviewed for Eligibility.
Eligibility Reviewed condition is mandatory for marking Self-Pay Claims as Billed. Once the Claim Status of Self-Pay Claims is changed from Entered to Billed, such records are removed from the Approve Claims screen.
Penalty Invoices and Employer Claims cannot be marked as reviewed for Eligibility as Eligibility is not applicable for them.

Mark Claim/s as Reviewed for Coding: Select the Mark Claim/s as Reviewed for Coding radio button and click on the OK button to mark Claim/s as Reviewed for Coding. The Coding Reviewed column on the Approve Claims screen displays the keyword 'Reviewed' for Claim/s that have been marked as reviewed for Coding. If Claim/s have not been marked as Reviewed for Coding then the Coding Reviewed column is shown blank. The 'Reviewed' keyword can be removed from the Coding Reviewed column by unchecking the Coding Reviewed checkbox on the ICD Pointers for Charge Codes popup for selected Claim.

Fetch Pri/Sec Ins Eligibility for DOS: Select the Fetch Pri/Sec Ins Eligibility for DOS radio button click on the OK button to fetch Eligibility for both Primary and Secondary Insurance (if present). A hyperlink is then displayed under the Clm Pri. Eligibility Details and Clm Sec. Eligibility Details columns respectively. On clicking the hyperlink, the Insurance Eligibility popup gets invoked for the user to check the details.

Note:

If the last fetched Eligibility is in 14 days' time frame (7 days prior to DOS 7 days after DOS then Eligibility should not be fetched. If the eligibility is other than Active, then irrespective of timeframe, user should be able to fetch the eligibility.

For TPA, Self-Pay, Employer Claims and Penalty Invoices, when the user selects the Fetch Pri/Sec Ins Eligibility for DOS radio button and clicks on the OK button, an alert message, Eligibility is not applicable to Self Pay, Employer Claims & Penalty Invoices – Claim ID/s gets displayed in a popup with an OK button.

Mark Claim/s Ready To Send: With the property, claim.review.mandatory.mark.ready2send set to ON, select the Mark Claim/s Ready To Send radio button and click on the OK button. The Claim Status is changed to Ready To Send if -

Claim/s have been Reviewed for Eligibility

Claim/s have been Reviewed for Coding

Claim/s with 0 Errors

Claim/s with 0 Warnings

Claim is in Entered Status

With the property, claim.review.mandatory.mark.ready2send set to OFF, select the Mark Claim/s Ready To Send radio button and click on the OK button. The Claim Status is changed to Ready To Send if -

Claim/s with 0 Errors

Claim/s with 0 Warnings

Claim is in Entered Status

Note:

When the property, claim.review.mandatory.mark.ready2send is OFF , Eligibility and Coding Review are not required hence, the radio buttons, Mark Claim/s as Reviewed for Eligibility and Mark Claim/s as Reviewed for Coding are not displayed on the Set Claim/s Status / Parameters popup.

When Mark Claim/s Ready To Send radio button is selected and OK button is clicked on the Set Claim/s Status / Parameters popup, then the message, XX Claims marked as Ready to Send out of YY Claims is displayed in a popup with an OK button.

Ignore Warning/s and Mark Claim/s Ready To Send: With the property, claim.review.mandatory.mark.ready2sendset to ON, select the Ignore Warning/s and Mark Claim/s Ready To Send radio button and click on the OK button. The Claim Status is changed to Ready To Send if -

Claim/s have been Reviewed for Eligibility

Claim/s have been Reviewed for Coding

Claim/s with 0 Errors

Claim is in Entered Status

With the property, claim.review.mandatory.mark.ready2send set to OFF, select the Ignore Warning/s and Mark Claim/s Ready To Send radio button and click on the OK button. The Claim Status is changed to Ready To Send if -

Claim/s with 0 Errors

Claim is in Entered Status

Note:

When Ignore Warning/s and Mark Claim/s Ready To Send radio button is selected and OK button is clicked on the Set Claim/s Status / Parameters popup, then the message, XX Claims marked as Ready to Send out of YY Claims is displayed in a popup with an OK button.

Claims Batch (Please Select the Batch): If the property, use.claims.entry.batch is OFF, Claims Batch (Please Select the Batch) radio button is enabled but the dropdown is disabled whereas if the property, use.claims.entry.batch is ON, both the Claims Batch (Please Select the Batch) radio button and dropdown are enabled for the user to select a Claim Batch. Claims Batch (Please Select the Batch) dropdown consists of all open Claim Batches stored on the Settings → Claim Batches screen. Along with the Claim Batch number, the Claims Batch (Please Select the Batch) dropdown displays the Batch Creation Date, Code of the Location assigned to the Batch and Code of the Business Unit assigned to the Batch. Select the appropriate Batch and click on the OK button.

Note:

If the Batch has the same Batch Creation Date as the claim DOS then the message, Batch is Associated Successfully. is displayed in a popup with an OK button.

On trying to associate Claim Batch for multiple Claims, a message, Batch is assigned to XX Claims from YY selected Claims is displayed in a popup with OK button.

If Batch is not associated then the message, Batch is Not Associated. is displayed in a popup with an OK button. Few reasons due to which Claim Batch might not get associated are: Batch Creation Date is less than Claim DOS, Batch is already assigned, Claim Status is On Hold, Claim having a Batch Assigned is Reopened, Property, use.claims.entry.batch is OFF, Claim having no Batch Assigned is reopened and the property, use.claims.entry.batch is then set to ON.

On Hold (Please Select the Reason): If user selects the radiobutton On Hold then the Reason to Keep Claim On Hold is mandatory to select. If the Reason is not selected then an error message Please select On Hold Reason while marking the claim On Hold is displayed.

Note: The Claims which are kept on HOLD gets revert to Entered status if any of the claim is displays the inbuilt validations, Scrubbers, CCI edits, Global Period edits or Medical Necessity Edits.