How to identify and deny duplicate claims within EZ-CAP®

While SymKey’s Batch Processing module allows you to create virtually limitless custom scenarios to modify or process claims, there are also several pre-programmed scenarios built into the SymKey® Professional and Hospital Claims modules.

Denying Hard Duplicates with SymKey® for EZ-CAP®

One of the most widely used SymKey® for EZ-CAP® scenarios automatically denies a list of hard (exact) duplicate claims in EZ-CAP® by adding a user-defined adjustment code and adjustment amount, zeroing out the net pay on the line/claim, and forcing the claim to status 1 for release to payment. This scenario can also be used to zero out the contract value of each line.

How do I know which claims are duplicates?

SymKey’s built-in Hard Duplicates module (a.k.a. Duplicates Finder) generates a list of duplicate claims to deny based on your specific business rules’ definition of what constitutes a duplicate claim.

Identifying Duplicate Claims in the Hard Duplicates Module
After selecting whether to look at Professional or Hospital claims, select which demographic fields must match a previously received claim in order to categorize the new claim as a duplicate (matching Member ID, Provider ID, Vendor ID, Primary Diagnosis, and Place of Service are good indicators of a duplicate claim).

Identifying Duplicates at the Detail Claim Line Level
Similarly, you can search at the detail claim line level to match exactly between the new and previously received claim on “Date of Service From and To,” “Service Code,” “Billed Charges,” “Capitation Flag,” and each of the four line modifiers.

Additional Filter Criteria
There are additional filters to only look at claims that EZ-CAP® has identified as duplicates with the P7 “DUP” pend flag, to only look for duplicates that are EDI claims, were received between certain dates, and/or match specified EZ-CAP® statuses. Custom filters can be quickly configured within the module to target a duplicate claim list to specific members, providers, vendors, CPT codes and several other fields. You can also add your own custom SQL code to the custom filters as matching criteria.

What if the previous claim was denied or has not been paid yet?

The Hard Duplicates module gives you the option to identify claims as hard duplicates only if the previously received claim resulted in a payment (Net Pay > 0). This prevents duplicate claims from being denied if the original claim was also denied (so you can review the new claim and decide whether the initial denial was legitimate) or if the original claim has not been paid yet (so the initial claim and the new claim are not both identified as duplicates and subsequently denied).

How do I create lists of claims to process with other SymKey® scenarios?

If you would like to auto-generate lists of claims to process with other SymKey® scenarios, you can use an external application such as Crystal Reports, SQL, Microsoft Access or any other reporting tool that can perform a structured query on the EZ-CAP® database(s) and produce either a list of claims for the standard SymKey® scenarios or a list of claim numbers and other required fields as desired for Batch Processing. HCIM’s product support staff is available to help you design these reports based on your organization’s unique business rules.

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.