Fixing Claims in the submitted State
It is comically common for Wellsky to not work properly. Sometimes they may neglect to return adjudication files necessary for reconciling claims.
Because SpokeChoice keeps claims in a "state" (Unapproved,Ready,Submitted,Paid or Written off) a claim could get "stuck" in one of these states without an adjudication file.
If Wellsky does not return an 999 file and a claim was denied by Harmony, then those claims in that "submitted" state will remain as such.
Determining if a claim is in the submitted state.
If you want to know what claims are "stuck" in the submitted state you can do so easily by going to homecare-billing and choosing the freeform search. Build a filter for the period in question and look at all claims in the submitted state.
By finding those claims you can then determine what batch was used to send them to the payer.
NOTE: Keep in mind that there is a specific process for reconciling claims in SpokeChoice that follows an EDI billing process and venturing outside the process can result in claims that get stuck in a circle of denial if you are not sure what you are doing.
You should always:
1) Ensure you have read in all 835 files prior to doing anything to resolve this issue.
2) Ensure that the claim is NOT in Wellsky
3) Ensure that the claim is NOT in PBS files on FOCUS.
If the claim is in the PBS files in FOCUS either denied or paid you MUST use the EDI workaround process to clear you claims. This requires you download PBS reports and use them to reconcile claims.
If the stuck claims are not in Wellsky and/or PBS Files (FOCUS) then you need to determine why they were denied manually since you did not receive a 999 file back from Wellsky. This is typically because the address or Diagnosis code was wrong on the client. Ignoring this issue will result in the claim yet being denied by Harmony again and if 999 files are not being returned by Wellsky then you are in a loop.
Deleting the batch
As mentioned above deleting a batch and circumventing the reconcile process is VERY dangerous and would mean you get claims stuck in a loop (limbo) that were paid and keep denying so use this only as a last resort to bring the claim back to a ready state.
NOTE: If you find that a claim is denying after you do this please do not ask why it is denying unless you have checked all PBS files for payment and used the EDI workaround to reconcile them or manually mark them as written off or paid.
Deleting the 837 payment Batch will bring all unpaid (submitted) claims back to ready. To find the batch use the freeform search as detailed above and hit the history icon on the claim to see the most recent batch number.
Then select Homecare-billing-Batches and find the batch in question.
Then hit the delete button on that batch.
KEEP MIND MIND THIS WILL BRING ALL CLAIMS THAT ARE NOT RECONCILED BACK TO THE "READY" STATE. This means that any paid claims that are not marked as such will now go back out and denials will ensue with your next 837 billing file. This is a very DANGEROUS thing to do and doing this means you could be receiving denials for many many claims that were indeed paid on any subsequent 837 files you produce. This is WHY it is important to follow all the other processes listed in this article prior to doing this, in particular the EDI Workaround