AlphaMCS Finance: Claim Maintenance · Confidential and Proprietary. Last Update Date- Sep. 10, 17...

AlphaMCS Finance: Claim Maintenance

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Last Update Date- Sep. 10, 17 1

Claim Maintenance

Claims management and overview is conducted in the Claim Maintenance module. Here, the user can

research and view the history of claims, manually review pended claims, and override claim decisions.

Select the claim maintenance Filter button to search for a claim.

From the AlphaMCS Menu, select

Finance, Claims, then Claim

Maintenance.




The Claim Maintenance Filter form will open. Search for claims by Claim Header ID, Adjudication ID and

other claim related criteria. Any combination of criteria can be entered to search for claims, however, at

least one or more additional field needs to be completed with valid information to receive results.

After filtering claims, any claim lines that fit the criteria entered by the user will be returned. Each claim

record displays the Claim Header, Received Date, Claim Line From Date, Claim Line To Date, Provider ID,

Provider Name, NPI, and Patient information. Select an individual claim record for additional information

about that claim line, or select the symbol to see additional information about all the claim records

returned.

Claim Header ID supersedes all other filter values.

Choose a Date Type to use From Date and To Date. Date fields become required if ‘DOS’ is selected as the date type.

Select Manual Review Required in the Status field to locate claims that require manual adjudication.




Once a claim line is selected, demographic information about the member will display at the top. Click the

small blue triangle to expand and view additional information. A selected claim record will also expand to

reveal additional information about the claim, and reveal several buttons that provide options for

processing, providing details about claim adjudication, and other relevant member information. They are

Re-adjudicate, Revert, Patient Details, Research Comments, View Claim, View 837, Details, and Quick

View.

The Quick View Button is a very useful feature that allows the user to quickly view pertinent member and

claim detail information related to the selected claim header in one place, with one click.

The small blue triangle next to the member information header can be expanded to view additional information wherever it is present

in AlphaMCS. Hereafter, this information will not be viewable in this document to protect member privacy.




Select the Re-adjudicate button to re-adjudicate the selected claim line. This action can be taken if the

claim approved/denied in error, or any changes have been made in AlphaMCS that may alter the ending

status of the claim. For example, if service mapping was incorrect during initial processing, and was since

corrected, or a provider’s contract or profile updated to allow for approval upon re-adjudication. Select

the reason for re-adjudication from the drop-down options. A comment is also required for this action.

Select Save.

Select the Revert button to revert the selected claim line. The user would select this option if a claim was

approved in error and recoupment was necessary. Select the reason for reverting the claim from the

drop-down options. A comment is also required to for this action. Select Save.




Use the Patient Details button to review and filter the selected member’s Diagnosis history, NC Tracks

Benefit Plans, Insurance, and Authorization information. All related member information is displayed

here, reducing the need to move between modules, thereby streamlining research and workflow.




Select the Research Comments button to review previously entered.

Select View Claim to review a ‘read only’ copy of the CMS1500 or UB04 for the claim if the claim type is

Professional (PF) or Institutional (IF), respectively. A copy of the claim can also be printed from this

location by selecting Print at the bottom of the form.

The View 837 button will allow the user to view the 837 file received by the MCO that the claim was

submitted on, if the claim type is PF or IF. Please note that this document will need to be downloaded in

order to review.

Select the header claim Details button to drill down and review claim lines and related provider contract

information associated with the claim. All claim lines included under the selected claim (header) can be

viewed here. Notice that the claim header and provider information is displayed at the top of the page.

Selecting Deny Claim will deny the claim at the header level. This means that all claim lines will be denied.

Select the Denial Reason and enter a comment in the Comments section to Save.

Select Close Record at any time forward to return to the claim header level of the claim.

Research comments can be entered once the user drills down to the Adjudication Line page’s Details screen.




Once a Claim Line is selected, the Adjudication Lines, along with additional claim line level information is

displayed, allowing the user to drill down even further.

The adjudication line grid records each time a judgment or decision was made on a claim line, and the

subsequent action taken. Select Filter to search within each line by Adjudication ID, Status, From Date,

To Date, Authorization ID, SAR ID, Capitated, and Paid. Select the Duplicate Claims link to display any

duplicate claims submitted.

Remember, the claim line(s) displayed is determined by the claim header selected under Claim Maintenance.




To override a claim line, choose Override from the selected claim line. Choose a Other Adj. Amt. Reason

and enter a comment in the Comments section to Save.




Select an adjudication line to view additional information about the claim line’s adjudication process.

Links are provided to download RA Reports and review Outgoing 837 (OG 837) History, Adjudication

History, and Reason History.




At this level, the user can also manually adjudicate a claim line, as well as review and add adjudication

details to the claim.

To manually adjudicate a claim line, select the Adjudicate button. Notice that the claim information is

prepopulated. The Approved Amount, Final Status, Reason, and related Comments are required details.

Select the Details button to add and review research comments, and to view credit memos and billing

details associated with the claim.

Research Comments can be entered as member information that related to claims submission is reviewed.

This information can also be viewed on the header claim level. Select the Add button for each comment

added.

If a claim is paid with a Credit Memo, information about the source of the credit memo, the claim line the

memo was applied to and check ID the credit memo was applied to can be located here.

The Billing Details section reflects any action taken after the claim is sent upstream to NC Tracks on a OG

837.




The Provider Contract button displays the contract information of the service provider associated with

the claim.




Please note that an additional header option is available when reviewing IP claims. The EOB option

enables the user the search for existing EOBs, as well as add documentation to create an EOB.

AlphaMCS Finance: Claim Maintenance · Confidential and Proprietary. Last Update Date- Sep. 10, 17...

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