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This process allows for posting payment information from
payer remittances (ANSI 835) to billed claims in the data based.
Payment information is matched to billed claims on a number
of elements including facility, patient number, service dates,
billed charges and date the claim was billed. Where a match
occurs, the ANSI 835 data segment and an EOB based on that segment
are attached to the billed claim. Both the 835 segment and the EOB
are available to view or print.
When a payment matches a billed claim the system determines
if a secondary payer claim must be created. A secondary claim is
created when the primary payer reduced their payment by a
deductible, coinsurance or other copay, the payer did not
automatically cross their payment to the next payer, and a
secondary payer is on the claim. When a secondary payer claim is
required, a copy of the original claim is made active, updated
with the payment information including amounts paid, dates paid,
payer ICN, and appropriate value codes. The new active claim is
subjected to Claim Agent’s payer specific edits. Like any
active claim, modifications to the claim may be made by the user.
Claim Agent allows the user to determine if a secondary
payer may be billed electronically or must be paper billed. This
determination of billing route allows for electronic billing to
electronically capable second payers and printing of paper claim
forms and EOB for paper only secondary payers.
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