The claim exception information includes:
Before any claims are processed in ND MMIS, the claim exception information and tables must be set up using the Claim Exception function of Rules Management.
The claim exception information includes:
The Claim Exception Code page allows you to search, add, or edit the exception codes used in processing claims received from providers and trading partners.
Claim exception information is provided in two main panels on the page:
Header information consists of the claim exception code, beginning date, ending date, and a short and long description.
The detail information is located on the right side of the Claim Exception page. There are four tabs of information:
The claim exception code and corresponding descriptions and effective dates, along with resolution and response information are applicable to all lines of business (LOBs).
The override information contained on the main tab and the disposition information can be specified for all LOBs or a specific LOB.
The dispositions are contained in tables for each claim type that has been established in the system. They are used during the claims process to determine the dispositions of the claims and when a claim exception can be forced paid or denied.
At least one row of detail data is required on the Disposition table when defining a new exception code.
The resolution information is used by the claims specialists as they process the claims corrections. The exception is displayed in the Exception panel on the Claims Correction page. It only provides the claims exception code.
The claims specialists can click the Read complete resolution text link below the short description in the Exceptions panel on the Claims Correction page to obtain the short description of the error.
The claim exception response text is used for troubleshooting denied claims with the member or provider. Denied claims are reported on the provider's remittance advice.
How to Search for a Claim Exception
How to Add or Edit a Claim Exception
How to Delete a Claim Exception
How to Delete Detail Information from a Claim Exception Code
How to Void Detail Information on a Claim Exception Code
Search Claim Exception Page
Claim Exception Page
Version as of 5/16/14.
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