| · | A TPA issues a refund check back to you when they discover that you over-paid on a claim for some reason.
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| · | A TPA returns an entire check because they have determined that some of the items on it should not be reimbursed to the group and they would like you to re-issue the check for a corrected amount.
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| · | A specific claim check gets lost between you and the TPA and you need to void that check and issue an identical one.
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In all of these situations, the TPA is not submitting any new charges, so you do not want any entries that you make to have any effect on the total submitted amount for the claim. Follow the steps below to handle the three situations listed above.
Voiding the Original Payment
In the case of a returned check or a lost check, the first step is to void the original payment. If you are dealing with a refund, you can skip to Processing Items That Should Not Have Been Paid. To void the original check, first add a new submission to the claim that the check was for. On the submission screen, the Description could be something like 'Returned Check #1234' or 'Reissue Lost Check #1234'. As mentioned above, the Amt Submitted will be 0. Your new submission should look something like this:
Save your new submission and then click on Process Submission to go to the processing screen. Once there, you are going to go to one of the Entry tabs and enter a line item to void the original payment. The service dates can be any valid service dates for the employee. You could enter the range of dates that the original check covered or you could just pick any other date to use. For the Item Description you could again reference the original check number that you are backing out. Since we don't want to change the total submitted amount of the claim, the Item Amt will be zero. Now if we enter the amount of the check we are voiding in the Ineligible field, the payable amount for the item will be equal to the negative of the check amount. You will also have to enter an Ineligible code. You could set up an ineligible code specifically for this purpose so that the item would be explained clearly on the EOB. Finally, since the Ineligible Amount is greater than the Item Amount, you need to change the Item Type for this item to R, which stands for Return or Refund.
Now you can go to the Summary tab and you should see that the system is about to release a payment equal to minus the original check amount. Go ahead and release this payment. After you release the payment, the summary screen should look something like this:
Now you need to post the returned/lost check number to the payment you just released. Click the following links to learn how to Issue a Claim Check and then Post a Claim Check. In this case, the check you are posting is for a negative amount and the check number you use will be the number of the returned/lost check.
If you are reissuing a lost check, continue to the next paragraph to reissue the check you just voided. If you are processing a returned check that has some items that should not have been paid and the TPA wants you to reissue the check for the corrected amount, or if you are processing a refund for items that should not have been paid, skip to Processing Items That Should Not Have Been Paid.
To reissue the lost check, you now need to go back to the new submission that you created in the steps above and add one more line item. You can use the same dates and description as the first item you entered. Again the Item Amount is zero. This time, the ineligible amount is the negative of the ineligible amount on the first line item. You can make the EOB more self-explanatory if you have an ineligible code specifically for this purpose (something like RE - Reissue Lost Check). Finally, make sure that the Item Type is set to R like in the first line item. Notice that the net effect of the two lines is 0 for both Item Amount (Submitted) and Ineligible. Go to the Summary tab and you should be able to release a payment that is equal to the amount of the check that you are replacing.
Processing Items That Should Not Have Been Paid
You may have a refund check for items that the TPA determined should not have been reimbursed to the employer or you may have a check that the TPA returned that was for both valid items and items that should not have been paid, but the TPA wants a corrected check to be sent. In the case of the returned check, make sure you follow the steps above for Voiding the Original Payment before you proceed with these steps.
In both of these cases, the adjustment you need to make at this point is to reflect that items that were previously released should have been ineligible. You have a couple of choices of where you do this. If it is a few items or most of the items are on a single submission, you can do the adjustments in each submission that has items that need to be made ineligible. This method will make the EOB more self-explanatory. However, if you have many items from many different submissions and you don't want to track them down and enter the adjustment in the correct submission, you can just add a new submission and enter the total ineligible as a single line item.
To make a previously released item ineligible in the original submission, go to the processing screen for that submission and go to one of the Entry tabs. Add a new line item and make the service and paid dates the same as the original item that was paid. You can use the Item Description field to indicate the Item Number(s) that you are adjusting with this item. The Item Amount should be zero (the TPA is not submitting any new charges) and the Ineligible amount should be that amount that was previously considered eligible but is now considered ineligible. Put in an Ineligible Code to indicate why it is ineligible. Finally, make sure the Item Type is set to R for Refund. You should end up with something similar to the screen shown below.
Notice the Payable amount at the bottom right of the screen shown above is negative. Repeat this process until all of the items in this submission that are now considered ineligible have been adjusted. Then go to the Summary tab and release the negative payment. If the original items were in multiple submissions, repeat this process for each submission that contains some of the now ineligible items. When you are done, you should have one payment released for each submission that was effected and these payments should add up to the total amount of the refund check or the total amount of ineligible items in the returned check.
If you want to lump all of the newly ineligible items into a single entry instead of adjusting each submission, then create a new Submission, enter zero for the Amount Submitted, and enter the Description or Notes to indicate the purpose of the submission. Then go to Process Submission and on one of the entry screens, enter a new line item, enter whatever dates and description you want, enter an Item Amount of zero, an Ineligible Amount equal to the total of the items that are newly ineligible, an Ineligible Code, and set the Item Type to R. Then go to the Summary tab and release the negative payment that results.
If you are processing a returned check and now need to issue a corrected check, skip to Issuing the Corrected Check. If you are processing a refund check, the final step is to post the check number of the refund check you received from the TPA to the payment(s) you just released. Click the following links to learn how to Issue a Claim Check and then Post a Claim Check if you don't already know how to do these steps. In this case, the check you are posting will show for a negative amount and the check number you use will be the number of the refund check.
Issuing the Corrected Check
In the case of a returned check that needs to be corrected and re-sent, you have taken the steps above to void the original check and then to process the items that should not have been paid. The final step is to issue a corrected check. In the first step, you voided the original check, so that the total paid on the items covered by the original check is then zero. Next you marked the items that should not have been paid as ineligible which generated negative payment records totalling the amount of the now ineligible items. So the progress of the payments looks like this (with some example numbers):
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Description
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Amount
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Status
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Original Check
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15,500.00
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Posted
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Void Original Check
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-15,500.00
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Posted
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Ineligible Items Submission 1
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-150.00
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Released
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Ineligible Items Submission 7
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-250.00
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Released
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You can see that the total Released is now equal to minus the amount of the newly ineligible items (-400.00 in the example), so if you want to finally release a corrected check that is equal to the original check amount minus the newly ineligible items, you need to add one more payment equal to the original check amount. To enter this payment, go back to the new submission that you created to void the original check in the first step of this process. Add a second item to that submission that has the same service and paid dates. The Item Description can be something like 'Reissue corrected payment.' The Item Amount is again zero and the ineligible amount is the negative of the ineligible amount in the first item. Again set the Item Type to R for Return. When you go to the Summary tab you will release a payment that will be equal to the original returned check amount. However when you go to Issue a Claim Check, this payment will be added to the payment(s) you released for the newly ineligible amounts and the total will be the correct amount that should now be paid.
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Description
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Amount
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Status
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Original Check
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15,500
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Posted
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Void Original Check
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-15,500
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Posted
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IneligibleItems Submission 1
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-150
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Released
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Ineligible Items Submission 7
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-250
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Released
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Reverse the Void transaction
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15,500
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Released
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Total New Check Amount That Will Be Paid
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15,100
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