Recalculate a claim

You can calculate multiple accounts simultaneously by separating account numbers with a comma. If there are claims that match your criteria, a message informs you that the recalculation task was queued successfully. If no claims match your criteria, a message informs you that no claims met your selected criteria, and to try again.

To recalculate by account number:

1. In the Recalculate Claims tab, click the Patient Account Number option.
2. In the Patient Account # field, enter the account number.

3. From the Claim Type drop-down, select the type.

   • Institutional A claim billed from a hospital or institution as opposed to billing from a physician's office.
   • Professional A claim billed from a physician's office as opposed to a hospital or institution.
   • All
4. From the Claim Status drop-down, select the status:
   • Live Claims Only
   • All
5. From the Simulation drop-down, select the simulation.
6. Click Recalculate.

IMPORTANT: This option should only be used if you are using the system’s Claim Number / UCRN feature.

If any claims match your criteria, a message displays that says the recalculation task was queued successfully. If no claims match your criteria, a message informs you that no claims met your selected criteria, and to try again.

To recalculate by Claim Number / UCRN Usual, Customary and Reasonable Number:

1. In the Recalculate Claims tab, click the Claim Number/UCRN option.
2. In the Claim #/UCRN field, type the number.
3. Select the Claim Type:
   • Institutional A claim billed from a hospital or institution as opposed to billing from a physician's office.
   • Professional A claim billed from a physician's office as opposed to a hospital or institution.
4. Select the Claim Status.
5. Select the Simulation.
6. Click Recalculate.

The date range option allows you to select all claims that fall between a specific date range and recalculate them.

To recalculate by date range:

1. In the Recalculate Claims tab, click the Date Range option.

2. In the Date Type field, select the type of date:

   • Discharge Date – Date the account was discharged
   • Admit Date – Date the account was admitted
   • Submission Date – Date the bill was submitted to the payer for reimbursement

3. For the Start Date and End Date fields, select the desired dates.

   You can enter dates manually, or use the drop-down calendar. Clicking any date sets that as your start/end date.

   

4. Select the Claim Type:
   • Institutional A claim billed from a hospital or institution as opposed to billing from a physician's office.
   • Professional A claim billed from a physician's office as opposed to a hospital or institution.
5. Select the Claim Status.
6. Select the Simulation.
7. Click Recalculate.

If there are claims that match your criteria, a message informs you that the recalculation task has been queued successfully. If no claims match your criteria, a message informs you that no claims met your selected criteria, and to try again.

Selecting the Contract option allows you to select whole contracts. Calculating by contract gives you added flexibility by allowing you to filter down into contracts, versions, or even to the provision level. For example, to calculate only an outpatient provision of a contract, you can drill down to that provision and select it for recalculation.

In the following example, a user is recalculating provisions 1, 2, and 5 of their Cigna PPO contract, as well as their entire KHA Managed Care contract.

Notice that the Contract option also includes the same features as the Date Range selection window, allowing you to narrow your criteria even further.

To recalculate by contract:

1. In the Recalculate Claims tab, click the Contract option.
2. In the Contracts table, from the Current View drop-down, select the desired simulation.
3. Select the desired contract/version/provision to recalculate. You can select more than one.
4. In the Date Range section, enter the date range criteria (if you want to calculate the entire contract, then entering date information is not required).
5. In the Enter a name for the task field, type a name for this recalculation.
6. Click Recalculate.

If any claims match your criteria, a message informs you that the recalculation task was queued successfully. If no claims match your criteria, a message informs you that no claims met your selected criteria, and to try again.

This option allows you to calculate claims for a single insurance plan code The combination of an Org Code and a Payer Code. instead of calculating all the insurance plan codes assigned to a contract version. For example, you can use this option when a new insurance plan code has been added to a version and you do not want to re-process an entire version and all plan codes, just the claims with the new code.

To recalculate by insurance plan code:

1. In the Recalculate Claims tab, click the Insurance Plan Code option.

2. In the Date Type field, select the type of date:

   • Discharge Date – Date the account was discharged

   • Admit Date – Date the account was admitted

   • Submission Date – Date the bill was submitted to the payer for reimbursement

3. For the Start Date and End Date fields, select the desired dates. You can enter dates manually, or use the drop-down calendar. Clicking any date sets that as your start/end date.

4. Select the Claim Type:

   • Institutional A claim billed from a hospital or institution as opposed to billing from a physician's office.
   • Professional A claim billed from a physician's office as opposed to a hospital or institution.
5. In the Claim Status field, select whether to use Live claims or All.
6. In the In. Plan Codes table, do the following:
   1. In the Current View field, select the desired simulation.
   2. In the list of insurance plan codes, expand the organization and select the check box for the desired code. You can select as many codes as desired. You can also select the parent Org. code instead, which recalculates all claims that have that Org. code, including all the Payer codes associated with that Org code.
7. Click Recalculate.