About c alculating claims
Claims calculation is the process by which a claim is filtered through the defined contract structure to generate a claim payment voucher and a total expected payment amount. Claims are calculated in Axiom Contract Management in two ways:
- Nightly import process — Occurs during the import process and is done without any user intervention.
- On-demand calculation — Users can perform ad-hoc claim calculation from the Recalculate Claims feature, and also while viewing a claim from the Claim Detail page. Administrators can recalculate claims from the Recalc History page, and calculate simulated adjustments to claim charges.
Typically, every claim that enters the system calculates automatically during the nightly auto-import process; however, there are times when you need to manually recalculate a claim using the ad-hoc methods.
You might need to recalculate a claim for several reasons. The most common reason is a contract term modification. If a claim is calculated on a specific clause of a contract and that clause is adjusted in a way that the claim now qualifies for another clause or rate, a recalculation is warranted.
Every new claim entering the system that has a matching Contract → Version → Provision → Clause/Term will automatically generate an expected payment during the auto-import process. This ensures that new information entering the system can be used during reporting and other analysis. No user intervention is needed, but it is important to note that if the contract structure is not kept up to date, then new claims that enter the system will not generate an expected payment. It is also important to note that even though a contract may exist for payer, if it is not modeled accurately, then the expected payment information will probably be inaccurate.
Keep an eye on contracts approaching expiration and make sure to extend the expiration date (if applicable), or model the new contract in Axiom Contract Management.
You can select to recalculate a claim at any time using the Recalculate Claims feature (Claims > Recalculate). You can recalculate claims by a variety of criteria:
- Recalculate by patient account number
- Recalculate by Claim Number/UCRN
- Recalculate by Date Range
- Recalculate by Contract
- Recalculate by Insurance Plan Code
NOTE: You can also recalculate a claim from the Claim Detail page.
