Do you receive reversals of previously adjudicated claims?
Check out this guide to learn how to record and review these responses through Jane.
I’m short on time, so take me to:
- insurer denied the claim and is now paying
- insurer paid the claim and is now paying an additional amount
- insurer is paying and taking back that amount in the same response
- insurer is taking back all or a portion of a previously paid claim
- insurer is recovering an overpayment on a previously paid and unrelated claim
If the insurer is changing how they originally adjudicated a claim, then you will get two new claim responses in the remittance:
- a claim response that reverses the previous claim/payment (Reversal). This claim response typically includes all negative amounts to reverse the previously allowed, paid, and patient amounts
- a claim response that states the new total adjudication amounts of the claim. “Total” means if an insurer paid you $20 originally, and then decides that they will actually be paying you $30, the new total amount on the claim response would be $30.
All these scenarios happen at the procedure level. A reversal can happen for just one procedure, but if that happens, the insurer has to reverse all the procedures. The net change might be the same for 3 or 4 of the procedures on a claim, but the remaining 1 procedure could be paid, paid more or taken from.
To manage these new claims responses, you’ll always want to manually mark the reversal as Reviewed (do not apply the EOB in this claim response - just acknowledge that you’ve seen it). Click into the checkbox to the left of the reversal, then select Mark as Reviewed top right.
Now let’s work through recording the new response by diving a little deeper into some common scenarios.
Positive reversal - insurer previously denied and is now paying
The insurer previously denied the claim and is now paying (nice). The initial EOB was recorded as $0.
Steps: Hop into the EOB, click edit existing amounts, update the new paid amount and record this by clicking the blue apply button bottom right. Done!
Positive reversal - insurer previously paid and now is paying an additional amount
The insurer has already paid an amount, and is now paying more! As the paid amount has already been recorded in the EOB, we will need to update the EOB to record the additional amount.
Example: Insurer previously paid $30, and has sent a cheque for an additional $70.
If I click the View button to the right of the new response, I can see which procedure code the $70 is being paid towards.
Steps: Hop into the EOB, click edit existing amounts, add in the new paid amount and record this by clicking the blue apply button bottom right.
Overpayment Recovery/Negative Reversal (the easiest!)
Sometimes you’ll get lucky, and the insurer will communicate the re-adjudication and recover the funds in the same ERA.
Steps: Mark the reversal as Reviewed, hop into the EOB, and record this by clicking the blue apply button bottom right. Done!
Negative Reversal (Takeback) - insurer is taking back all or a portion of a previously paid claim
The insurer is taking back all or a portion of the previous payment on this claim. In the example below, $100 was previously paid, but they have re-adjudicated the claim and are now paying only $50.
Steps: Mark the reversal as Reviewed, hop into the EOB, and record this by clicking the blue apply button bottom right. This will create a credit in the original payment that was applied to this invoice.
Negative Reversal (Takeback) - insurer is recovering an overpayment on a previously paid and unrelated claim
The insurer is taking back money from a previously paid and unrelated claim and has adjusted the total amount paid on the current ERA you are processing which means you’ll be short $ and will see this message as you work through recording the responses
This can be tricky as somewhere along the way the insurer likely communicated that they were going to take back money (in this example $50) from a particular claim and remittance and we need to locate this information in order to create the credit to pay the current claim.
Once you know which past claim they are taking money from, you’ll unapply the insurer payment from the previous invoice which will create the $50 credit you need. The easiest way to do that will be to head to the Patient Profile>Billing >Purchase. Click View beside the date of service, scroll to the bottom and you’ll locate the linked insurer payment there.
Click into the link, unapply the payment then search for the current claim you’re recording.
Once you’ve located the claim, you can edit the EOB and record this amount which will pay your current response.
Do you have a question about claim reversals that wasn’t answered in this guide? If so, please reach out to our support team at [email protected]