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Manual claims creation

Updated on August 31, 2021

The SCE supports the manual entry of Professional, Institutional and Dental claims through a UX presented in the Claims Examiner Portals. Information on this is covered in the Manual claims entry section of the Operations section.

Claim case creation

When claims are created as cases in the SCE, as part of intake, they are assigned a status of New. The next step in the creation is the creation or assignment of a unique Internal Control Number (ICN) for each claim. This field is the primary field for searching for claims, displaying in the UX, the claim identifier in the outbound 837, 835 and 277, and used for communications with 3rd party application. The ICN is also incorporated into the Put and Post Claims APIs for the assignment of an externally generated ICN. The ICN is also commonly referred to as a Claim Control Number (CCN) or Document Control Number (DCN).

The ICN can also be entered manually or generated in the claim entry screens. If the ICN entered or submitted is a duplicate of an existing ICN, then event code SVE-0002 is triggered. In this situation, the ICN can be reentered or automatically generated.

ICN creation

The SCE can create a new ICN, which contains metadata on the claim, including media type, submission date and version. The ICNs generated by the SCE follow the following pattern: CCYYJJJMSSSSSSSSXX

  • CC = Century
  • YY = Year
  • JJJ = Julian Day
  • M = Media Type (for example: P – Paper, E-Electronic Batch, V – VAN POS, W – Web-POS)
  • SSSSSSSS = Sequence Number support for up to 99,999,999 claims per day
  • XX = Version (00 – Original, 01-99 – Version update via adjustment)

Deletion of claims

The SCE provides tools to delete claims from the system. Claims, not in a production environment (production level of 3 or below) can be deleted from the Actions menu. This will delete any claim from a work queue as well as create the appropriate accumulator negative transaction.

In addition, to the manual deletion, the SCE provides a way to cancel a large file of claims via a file containing the list of ICN’s to update. In this instance, a file containing a comma separated list of ICNs deposited in the file pickup directory will be processed. The process will cancel any claims from the system that are in a status of: New, Pending-Investigation, Pending-Recycle, Open-Error or Open-Processing. The statuses can be updated in the CheckForClaimStats table. This will enable a bad batch of claim to be cancelled from the system. On successful processing, the following will occur:

  • The audit trail will be updated with a message “Claim has been logically deleted”.
  • The row for the claim on the N837 table will be updated with a -3 status.
  • The statuses of the claims will be updated to Resolved-Cancelled

Note: if the file contains an ICN of a status that cannot be deleted (for example Pending-Approved, Resolved-Completed), it will not be processed.

Note: if the claim was open by an examiner during this process, the process will not get a lock on the claim to perform that update.

Any errors created during the deletion, for example, failure to find the appropriate ICN, will be added as a message to the system log.

Claim identifiers for processing

The SCE provides support for different configurations for each of the claim identifiers used in processing. The three identifiers are:

  • Chargeable / Standard claims
  • Reporting Claims
  • Subrogation Demand Claims

Each of these claim identifiers can have different processing requirements and configurations in the SCE. In addition, Reporting and Medicaid subrogation claims have different finalization routines.

Chargeable / standard claims

Standard claims are also called chargeable claims. They represent a bill for healthcare services sent by a provider to the insurance company or health plan, who review the claim for validity before paying the benefits recognized. In the SCE, a chargeable claim is submitted with a claim identifier of CH.

Reporting claims

Reporting claims contain detailed information about individual healthcare-related services provided by a managed care organization (MCO) or other state-designated managed care providers. Plans and States use the data for many purposes, including setting MCO rates, evaluating MCO performance, and providing detailed reports to appropriate stakeholders. In the SCE, a reporting claim is submitted with a claim identifier of RP.

Subrogation demand claims

Subrogation demand refers to the process that an insurance company uses to seek reimbursement for a claim that it has already paid to the responsible party. Subrogation demand claims are important to a healthcare payer or Medicaid state, if another party has been determined as responsible for all or part of the charges. In such cases, the insurance company or party who receives the claims may pay the claim, and then seek reimbursement from the other insurer. In an example of a patient, who has a primary coverage and Medicaid as a secondary coverage (last payer), only informs the provider about the Medicaid insurance. The service is rendered and the provider bills Medicaid as primary. Medicaid pays the claim as the sole payer (“pays out of turn”) and later determines that the patient had another medical insurance policy. To reclaim monies, the State submits claims using the subrogation demand identifier to the primary insurance after reconciliation of eligibility files. In the SCE, a subrogation demand claim is submitted with a claim identifier of 31.

Dental predetermination claims

The SCE provides the ability to handle dental predetermination claims. These claims are processed a little differently from a regular billable claim. In the dental claim, the Claim submission reason code (CML19) is submitted with a value of PB – Predetermination of dental benefits. This field indicates that the claim is a dental predetermination transaction. Other rules apply in this situation as the claim is processed:

  • The mandatory check for dates of service on the claim is removed.
  • The system uses the submission date to support benefit lookup and calculations in the absence of the dates of service.

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