A claims work list is an organized list of claims-related follow-up tasks. This work list is predicated on a set of claims work list rules, or criteria, that flag claims that need to be worked and establish a follow-up date and risk level. The claims are presented to the billing staff in a work list ordered by risk level and follow-up date. This ensures the highest priority claims are given appropriate attention.
Notes about Claims Work List Rules
- A claim cannot be associated with more than one rule. We avoid this by using risk and then follow-up days as the deciding factors.
- Risk level: The higher risk level trumps the lower risk level.
- Follow-up days: The smaller number trumps the larger number of follow-up days.
- Claims are populated to the claims work lists every night.
- The follow-up date is based on the claim’s status date.
- In this example, we selected a claim that is associated with the rule called Sample Rule, which set the number of follow-up days at 21.
- Since the claim’s status date is 2/5/2015, it coincides that the follow-up date is 2/26/2015.
- Note: This logic no longer applies if the follow-up date is manually updated.
Create a New Rule
- From the menu bar, click Admin and then click Claims Work List Rules.
- The claims work list rules that you have created display.
- To view the options menu, select the rule.
- To perform any of the menu actions, click the associated link.
- To create a rule, click Create New Rule.
- Enabled: Deselect this checkbox to disable a rule. Use this option when you do not want the rule to generate any claims, but you do not want to delete the rule.
- Clear Claims: Temporarily remove all of the currently displayed claims associated with the rule. Note: Claims will populate to claims work lists every night unless you delete the rule.
- Delete Rule: Delete the rule.
- Edit Rule: Edit the rule.
- View Claims: Navigate to the Claims Work List page. Display all of the claims associated with the rule.
- Enter a work list rule title.
- Select a risk level (default is 3).
- Select a work status (default is open).
- Assign the number of follow-up days (default is 7) by either clicking an option or entering a number in the field.
- Click a claim category (defaults to pending payment). Note: The claim activity and criteria options depend on which claim category you select.
- Select the time frame of the claims (default is three months). The time frame determines how far back claims with that status will be flagged and display in the claims work list. Note: A Finalized claim can only go back three months.
- Select a claim activity. You must select at least one.
- Click which criteria you want the claims flagged according to.
- To delete the criteria, click the X on the right side of the screen.
- Click Save Rule.
Claim Category and Claim Activity
The table lists the claim categories and the claim activities that can be selected for a claim work list rule, and the associated claim status(es).
| Claim category | Claim activity | Claim status |
|---|---|---|
| Not Billed | User Hold | User Hold |
| Not Billed | System Rejected | Rejected |
| Pending Payment | Billed |
Accepted Sent to Payer Received Info Requested |
| Pending Payment | Payer Rejected | Rejected |
| Post-Payment | Denied | Denied |
| Post-Payment | Finalized | Finalized |
| Post-Payment | In Appeal |
Accepted
Sent to Payer
Received
Denied
Finalized
|
It is important to understand that claims move in and out of a claims work list depending on the claim activity. A claim could also move from one claims work list to another. The following are a few examples of this behavior.
- A Not Billed rule for User Hold claims with a seven-day follow-up will be flagged seven days from the day it was originally put in User Hold. After the claim is billed and pushed to Accepted status, the claim is automatically unflagged from the Not Billed rule.
- A Pending Payment rule for a Billed claim with a 45-day follow-up will be flagged 45 days from the day the claim was put in Accepted Status. After payment is applied to the claim and the status is updated to Finalized or Denied, the claim is automatically unflagged from the Pending Payment rule.
- A Post-Payment rule for Denied claims with a five-day follow up will be flagged five days from the day the claim was changed to Denied.
Select Rule Criteria
The following are the rule criteria, which depend on which claim category you select:
Claim Total
- Enter the minimum and/or maximum totals.
- At least one total is required.
CPT Code
- All CPT Codes is the default.
- Search by code or description.
- Select a code and click Add to move the code to the right side of the screen.
- To remove a code, select the code and click Remove.
Group Codes
- Select at least one group code checkbox.
Payer Classes
- All Payer Classes is the default.
- Select a payer class and click Add to move the class to the right side of the screen.
- To remove a payer class, select the payer class and click Remove.
Payers
- All Payers is the default.
- Select a payer and click Add to move the payer to the right side of the screen.
- To remove a payer, select the payer and click Remove.
Reason Codes
- All Reason Codes is the default.
- Select a reason code and click Add to move the code to the right side of the screen.
- To remove a code, select the code and click Remove.
Underpayment Amount
- Only one selection is allowed.
- Expected Fee Schedule: Enter the percentage and then select the Fee Schedule from the menu.
- Expected Medicare: Enter the percentage.
- $0.00 Payment