The disposition configuration identifies how the claim will process based on the event code assigned. This step defines the action of the disposition (deny, suspend, informational, ignore) based on specific claim criteria. There can be multiple different disposition combinations based on key claim attributes. At least one disposition needs to be configured for the event code.
The following table details the primary fields used for the disposition. Fields with an asterisk (*) are required:
|Claim type*||The claim type used for this disposition. It could be All, or any of the types selected in the event code configuration.|
|Claim identifier*||The claim identifier used for this disposition. It could be All, or any of the identifiers selected in the event code configuration.|
|Submission type*||The submission type used for this disposition. Select All, New, Adjustment/replacement or Void/cancel|
|Media type*||The media type used for this. Select EDI POS, Paper, Electronic batch, VAN POS, Web POS or All|
|Processing start*||Processing start date for the disposition. The date the defined disposition becomes active in the system.|
|Processing end*||Processing end date for the disposition. The date the defined disposition becomes inactive in the system.|
|Action code override info||Action codes assigned on the claim that can be used to override this event code when it is set. This option is only valid for Deny and Suspend dispositions. To add action codes, select + Add action code.|
The suspend disposition has a wide variety of fields that are used to control how the system manages claims that have events set to suspend. The primary types of configurations are below, each having their own set of options.
- To be submitted to an examiner for manual resolution.
- To auto-recycle for a specified period of time before the claim is denied or requires a manual resolution.
- To set service level agreement (SLA) information for the resolution task, so the claim doesn’t age past a deadline.
- To set a claim hold to stop claim processing for a specified number of days.
The fields to configure the suspend disposition are listed in the table below and are available once a suspend disposition has been selected:
Information on the resolution action buttons that are assigned in the disposition configuration can be found in the Claims Resolution section of the Claims Operations chapter.
|This is the recycle configuration. It provides the ability to recycle the claim prior to making a disposition decision. The configuration supports hourly, daily, or weekly options to a maximum, after which, a configuration to deny or route the claim or line is applied.|
|Priority||The priority of the event code for a suspend configuration. If multiple event codes are reported on the claim, the highest priority pend will be presented for resolution first.|
|Default work queue||The default work queue for this event code. This is used to assign a specific work queue for this event code. If this is blank, then the default work queue on the system configuration is applied.|
|Claim level / line resolution process||The dedicated process that is presented in the resolution window to resolve an event code at the claim level or line level. If this is blank, then the default line or claim event resolution process on the system configuration is applied.|
|Resolution role||The user role required to resolve a claim with the event code.|
|Override event / Override role||Displays the Override event action on the guided event resolution UX. The user role able to override the event is also identified.|
|Replace event code||Displays the Replace event code action on the guided event resolution UX. The replacement event codes can be constrained to a list of codes by selecting the appropriate codes with + Add event code.|
|No action required||Displays the No action required action on the guided event resolution UX.|
|Update claim / Update claim line||Displays the Update claim or Update claim line action on the guided event resolution UX.|
|Deny claim / Deny claim line||Displays the Deny claim or Deny claim line action on the guided event resolution UX.|
|Cancel claim||Only applies to claim level dispositions. Displays the Cancel claim action on the guided event resolution UX.|
|Manually price claim line||Only applies to claim line dispositions. Displays the Manual price claim line action on the guided event resolution UX.|
|SLA available||Ability to set a specific service level agreement (SLA) for the resolution of the event code.|
|SLA*||Select the SLA rule associated with the event code. Selecting the SLA will display the Goal urgency increase and Deadline urgency increase fields with the values from the selected SLA. *Required when SLA available is selected.|
|SLA days type*||Definition for the type of days being referenced for the SLA: Business days or Calendar days. *Required when SLA available is selected.|
|SLA deadline days*||Contracted claim processing time made with an organization or department. *Required when SLA available is selected.|
|Organization name*||Department or organization identified as responsible for the event resolution SLA. The selection list is defined in the SLA section of the system configuration UX. The organization type is populated based on the selection. *Required when SLA available is selected.|
|Claim hold info available||Identifies if the claim should be held for a specified period of time before reprocessing.|
|Claim hold type*||A reference to identify the type of hold. Related to: External payer, Provider, or Internal. *Required when claim hold info available is selected.|
|Claim hold days type*||The definition for the type of days being referenced for the hold: Business days or Calendar days. *Required when claim hold info available is selected.|
|Claim hold days*||The number of days that the claim will be held based on the hold days type. *Required when claim hold info available is selected.|
|Claim hold begins on*||The date that the claim hold period starts: Claim receipt date or User specified date. If user specified date, the Select date field is available. *Required when claim hold info available is selected.|
Once the disposition has been configured, select Add disposition.
Multiple dispositions can be configured for the event code by selecting + Add disposition in the disposition configuration list.
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