QHR Product Ideas

When processing the unmatched there are at times scenarios that require matching individual items in a way that is not correctly reflective of the claims processing and may result in confusion if claims are audited at a later date.

• The health ministry adds a new tariff to a claim that has been submitted.

e.g. The procedure listed in the procedure report was excision of a lesion with local anesthetic and tray fee, but the local anesthetic was not submitted.  The health ministry staff have added the local anesthetic to the claim as a courtesy based on the supportive documentation provided..

• The health ministry changes a tariff that was billed to a different tariff.

e.g. A claim is submitted for multiple surgical procedures and a medical officer determines that one of the tariffs billed was incorrect.  The health ministry staff reject the incorrectly billed tariff and add a new tariff in its place.

In both of these scenarios the "extra" paid item has to be attached to something that is existing on the claim.  In the first scenario the local anesthetic would have to be matched to the excision for example.  This results in the fee for the excision appearing to be higher in value than it should be and does not easily show that a local anesthetic was added to the claim.

In the second scenario the rejected item would have to be matched to the originally billed item, then the newly added item would also have to be matched to the originally billed item.  This will not reflect the correct tariff and fee in the system, the fees paid will appear "off" and it is not easily shown that a different tariff was paid..

It would be very helpful to be able to take an unmatched item and "add it" to the claim as a new line, or single entry (separate "claim") in the system.  This way any other adjudication on the claim is unaffected, and everything is either paid, or rejected appropriately in the system.