Locating denied claims

system · July 24, 2015, 7:04pm

harleytuck wrote on Friday, July 24, 2015:

Hi Folks-
Trying to figure out how to track down denied claims I ran across
ViSolve’s 2013 forum posting with the definition of the denial group
code; that the denial reason will be displayed in the Billing Mgr and
that it appears when the claim returns a status of ‘7’.

But I can’t find what table the ‘7’ status is recorded in, and how does
it get there? Does one have to manually log denied claims somewhere,
and if so where? All in all, how does OpenEMR know that a claim has
been denied?

Thanks once again- Harley

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system · July 24, 2015, 8:48pm

fsgl wrote on Friday, July 24, 2015:

Hi Harley,

I think you are talking about Resubmission Codes 6, 7, 8 as explained here. They are not denial codes per se.

When a claim has been rejected & another has to be resubmitted, 7 is entered in Miscellaneous Billing Options, which will populate Box 22 of the CMS 1500 form, along with the reference number of the rejected claim, which goes in the adjacent box. See attachments.

There is no good way of recording denial reasons, except to make a note in Billing View.

system · July 25, 2015, 10:37am

fsgl wrote on Saturday, July 25, 2015:

Found the post in question.

The Billing Manager has a Status filter for denied claims.

There does not appear to be a list for Denial Group Code. Never seen it in Batch Billing nor in the EOB Posting Invoice.

The only other place where it can be used is ERA. We post manually. As a result we are unfamiliar with automatic posting.

If no other response in this thread, it may be simpler to email them.

system · July 27, 2015, 3:49pm

visolveemr wrote on Monday, July 27, 2015:

The claim status is set to Denied(7) while using ERA posting, as in the below links.

github.com

openemr/openemr/blob/master/interface/billing/sl_eob_process.php#L246


    if (empty($ferow)) {
          $pid = $encounter = 0;
          $invnumber = $out['our_claim_id'];
    } else {
          $inverror = false;
          $codes = ar_get_invoice_summary($pid, $encounter, true);
          // $svcdate = substr($ferow['date'], 0, 10);
    }
}


// Show the claim status.
$csc = $out['claim_status_code'];
$inslabel = 'Ins1';
if ($csc == '1' || $csc == '19') {
    $inslabel = 'Ins1';
}


if ($csc == '2' || $csc == '20') {
    $inslabel = 'Ins2';
}

github.com

openemr/openemr/blob/master/library/billing.inc#L108


//
function updateClaim(
$newversion,
$patient_id,
$encounter_id,
$payer_id = -1,
$payer_type = -1,
$status = -1,
$bill_process = -1,
$process_file = '',
$target = '',
$partner_id = -1,
$crossover = 0,
$submitted_claim = ''
) {


$sqlBindArray = array();
if (!$newversion) {
    $sql = "SELECT * FROM claims WHERE patient_id = ? AND " .
    "encounter_id = ? AND status > 0 AND status < 4 ";
    array_push($sqlBindArray, $patient_id, $encounter_id);

As per the 835 EDI, CLP02 contains the Claim Status code, whereas the value 4 represents the claim has been denied from the payer.

Thanks
OpenEMR Customization/Support Team,
ViSolve Inc
services@visolve.com | Phone: 408-850-2243
Demo’s @ ViSolve Demo Library

system · July 28, 2015, 5:25am

htuckjr wrote on Tuesday, July 28, 2015:

Thanks, fsgl, for your input. I’m not at my OpenEMR right now so I can’t check out your observation to find where the resubmission code is stashed. Sorry I didn’t mention it when I started the thread but yes, the original question came from seeing the ‘denied’ status filter in the billing manager. And I hadn’t seen anywhere either to manually enter a denied status.

Visolve- I see in the code you linked to where it writes the claim status code 7 in the table. Looks like the next step is looking in the era posting process.

As soon as I get to look into this I’ll post what I find- thanks y’all for the head start.

HT

system · July 29, 2015, 5:14pm

harleytuck wrote on Wednesday, July 29, 2015:

Hi All-
Ok, I also looked at the code on the Billing Manager form that contains the search criteria widget. It says Denied claims have a ‘7’ value in billing.billed; Unbilled has a ‘0’ there, Billed = ‘1’.

ERA’s next.

Thanks!- HT