FAQ: The 2010 CMS Fee Schedule was released and is effective retroactively. We have already paid claims for the last several months that now need to be repriced. Can SymKey automatically reprice them?

Yes, SymKey’s “Reprocess/Pend” standard scenario is a perfect automated solution for repricing paid claims and is very simple to use for EZ-CAP status 9 claims.

  1. Create a .txt file with a list of the paid claim numbers that need to be repriced
  2. Open the SymKey Professional Claims module
  3. Check the “Reprocess/Pend” checkbox about ¾ the way down on the left side
    Note: most of the screen will be grayed out and Source Claim Status 9 will automatically be selected.
  4. In the “Global Options” section at the top of the Professional Claims module:
    – Check the “Reprice Claim Lines” checkbox
    – Check the “Adjustment Code” checkbox
    – Select an adjustment reason from the drop-down list
    – Check the “Adjust All Lines” checkbox
  5. Click the “Process Batch” button

SymKey will automatically perform the following:

  1. Create a set of new claims in EZ-CAP status 3
  2. Duplicate the demographic and line detail for each claim in the input file
  3. Reprice each line to the new fee schedule
  4. Subtract the original payment from the amount due, resulting in a net pay of the difference in fee schedule amounts

Example:
The original claim paid $45.50 for a particular claim line.
Under the new retroactive fee schedule, the payment should have been $48.90.
Using the “Reprocess/Pend” scenario, SymKey will create a new claim with:
Claim Line Contract Value: $48.90
Negative Adjustment: $45.50, with the Adjustment Reason Code specified by the user
Claim Line Net Pay: $3.40

If you’re interested in more of the automatic benefits administration solutions that HCIM has to offer, call 888-454-0202, option 5 or e-mail us at info@hcim.com.

About HCIM

Since 2000, HealthCare Information Management, Inc. (HCIM) has delivered expert consulting services and robotic automation tools for small to mid-sized healthcare payer and managed care organizations. Our concierge consulting services include everything from core claims system procurement to go live, including configuration, migration, upgrades, reporting, benefits and fee schedules, user training, and project resourcing. We also offer strategic consulting in the areas of value based payments, population health, medical management, medical loss analysis and recovery, care management, provider contract modeling, data analytics, and business process reengineering/analysis.