Provider Claim Holds
Provider Claim Holds allow users to set up automatic Claim Delays based on provider credentialing. This is beneficial when the lack of credentialing or licensure will lead to a denial. Once the hold is inactivated, any associated charges will automatically be released from Claim Delay when the charge edits process runs again. Note: If the provider was being held for lack of credentialing with a government payer, you must ensure that in addition to removing any Provider Holds, you set up the provider’s related Billing Settings as well.
Create a New Provider Claim Hold
- Navigate to the Admin menu and select Providers.
- Search for a Provider by entering the Provider Code or the First and Last Name. Then click Search.
- From the Search Results, double click the line of the Provider.
- On the Provider Claim Holds card, click the New button.
- Complete the information on the Provider Claim Holds card, and click Save to create the rule.
- Hold Name: Enter the name of the rule and/or the insurance to identify the rule.
- Status: Select Active or Inactive from the drop-down.
- Date of Service Range: Enter the effective dates for the rule. You can backdate the Start Date for the rule, but it will only apply to charges posted from the current date forward. Leaving the End Date blank will apply the rule indefinitely, but you can not use a future date for the End Date.
- Claim Delay Reason: Use the drop-down to select the reason for the hold. The claim delay reason will display on the Delayed Claims page with any held dates of service.
- Location: You must select at least one location. Use the Search bar to enter a description or scroll through the options listed below to make your selection(s). Select Include future to apply the rule to locations added in the future.
- Insurance Class/Insurance Code: You may also select an Insurance Class or Insurance Code to apply to the rule. Again, use the Search bar to enter a description or scroll through the options listed below to make your selection(s).
- A confirmation message displays the number of updated charges and the total charge amount of those updated charges. Select Continue, to confirm.
- Back on the Provider page you must click Save to apply the new Provider Claim Holds rule to the selected Provider. Any charges for that Provider at the location specified and meeting any other hold criteria you chose will be put on Claim Delay (“L” status). Once you no longer require the hold, you can Edit the claim hold rule (see instructions below) and either enter the end date for the rule or make the rule Inactive.
EDIT A PROVIDER CLAIM HOLD
- On the Provider Claim Holds card, click the line of the provider rule you wish to edit.
- Make any adjustments to the rule. Select Inactive from the Status drop-down to deactivate the rule, if applicable. Click Save to apply your edits.
- Back on the Provider page you must click Save to apply the edited Provider Claim Holds rule to the selected Provider.