If you need to make changes to a claim that has already been Paid or Denied, you can revise the claim and resend it to the Funder directly from AlayaCare. If you have already resent the claim from the clearinghouse, you can also revise the claim in AlayaCare so that it matches the record in the clearinghouse.
The Revise option will be available on Open claims with a status of Paid or Denied with an Internal Control # (adjudication number). If a Paid or Denied claim that does not have an Internal Control #, you will need to enter it manually to revise the claim.
Revise and Reconcile a Claim with the Clearinghouse
If you have edited a claim directly from the clearinghouse and wish to update the record in AlayaCare, you should use the Revise claim to reconcile with clearinghouse option.
To begin, open a Paid or Denied claim and select the Revise button.
In the Revise Claim dialogue box, select Revise claim to reconcile with clearinghouse.
The Bill Code will be displayed below. Use the Procedure Code and Procedure Modifier fields to update the Bill Code.
You can also adjust the Quantity. Note, however, that changing the Quantity could result in Bank Time being lost if the entered Quantity differs from the amount calculated on the claim.
When you have finished, click Revise and Reconcile.
Once the claim has been resent through the clearinghouse, Revised will be displayed with the icon next to status. The checkmark icon indicates that the claim has been revised and reconciled with the clearinghouse rather than resent to the Funder from AlayaCare.
The icon will also appear next to Voided in the Resubmitted column in the Funder's claims list for claims revised and reconciled with the clearinghouse.
If adjustments were made to the Quantity, the Overridden Total Logged Through Clearinghouse will also be added to the Claim Breakdown card.
Revise and Resend a Claim from AlayaCare
To update the Bill/Procedure Code and resend the claim from AlayaCare, click the Revise button on the claim and select Revise claim in AlayaCare and resend to clearinghouse.
In the dialogue box, adjust the Bill Code as needed.
In certain cases, a conflict will arise if you change the Bill Code so that two claims become identical (meaning that the contain the same Visits with the same Bill/Procedure Code, Client ID, and Visit Start Date). When this occurs, you will receive an error message that explains how to proceed.
If you are revising and resending a Paid or Denied claim that conflicts with a claim that still has a status of Draft or Prepared, you will receive the following message: "This change conflicts with an existing claim. By changing the Bill Code to the above claim, Claim ID: XXX will be merged with Claim ID: YYY and resubmitted as one claim. Are you sure you want to resubmit? The claim will be marked for preparation, and ready to be prepared.
If you are revising and resending a Paid or Denied claim that conflicts with a claim that has a status of Sent, Acknowledged, or Accepted, you will receive the following message: This change conflicts with Claim ID: XXX, which is currently being assessed by the Funder. Wait for Claim ID: XXX to be open to perform this change. You will not be able to proceed with resending the claim.
If you are revising and resending a Paid or Denied claim that conflicts with a Paid, Denied, or Rejected claim, you will receive the following message: This change conflicts with an existing claim. By changing the Bill Code to the above claim, Claim ID: XXX will be merged with Claim ID: YYY and resubmitted as one claim. Are you sure you want to resubmit?
If you still wish to resubmit the claim with the Bill Code changes, click Revise and Resend.
Once the claim has been resent through the clearinghouse, Revised will be displayed with the icon to indicate that it has been revised and will be resent to the Funder.
The icon will also appear in the Resubmitted column in the Funder's claims list for claims resubmitted from AlayaCare.
The next time you prepare claims by selecting Mark for 837 Preparation, the revised claim will be prepared as well. Once it has been Prepared, it will be ready to send to the clearinghouse the next time you select Send 837 for the Funder's claims.