Managing insurance claims in DrChrono can sometimes pose challenges, such as claims remaining in "Balance Due," incorrectly moving to patient responsibility, or being rejected by secondary payers. This article guides in resolving these issues and preventing them in the future.
Common Claim Issues and Resolutions
1. Claim Stays in "Balance Due" Instead of Billing Secondary Insurance
A common cause for this issue is the "Auto Set Billing Status" setting, which changes the billing status to "Paid in Full" or "Balance Due" when an ERA is received. To resolve this:
Disable Auto Set Billing Status: Navigate to Account Settings → Medical Billing, and disable the "Auto Set Billing Status" option. Then, resubmit the claim.
Create an Adjustment Master Rule: If you want the insurance balance (e.g., deductible amounts) to remain under the payer instead of moving to the patient, create an adjustment master rule for that payer. Set the rule for the "deductible" reason code to "No Action Required." This ensures the balance stays under insurance for all claims associated with that payer.
2. Claim Moves to Patient Balance Instead of Submitting
This issue often occurs when an archived insurance entry in the patient’s Insurance History overlaps with the claim’s date of service (DOS). To fix this:
Open the patient’s Insurance History.
Identify any archived or older insurance entries that lack a payer name or payer ID or are no longer active.
Edit the archived insurance entry and set its End Date to a date before the claim’s DOS.
Save the changes, then return to the claim and resubmit it by setting the Billing Status to "Bill Insurance," checking "Resubmit," and selecting "Verify & Save."
This ensures the correct active insurance is recognized for the claim.
3. Secondary Claim Rejected with "Adjudication Date Cannot Be in the Future"
This rejection occurs when the secondary payer’s adjudication or check date is set later than the date the secondary claim was submitted. To resolve this:
Correct the adjudication or check date so it is no longer in the future relative to your submission date.
Resubmit the secondary claim for processing.
4. Preventing Claims from Going to Secondary Insurance
If you want the remaining balance to be patient-responsible after posting the primary EOB, follow these steps:
Open the charge line in the Billing Details screen.
Add an adjustment by clicking the blue plus (+) on the right side of the charge line.
In the Adjust Reas (Adjustment Reason) dropdown, select "Transfer Balance to Patient."
This moves the remaining balance from insurance to patient responsibility, ensuring it won’t bill a secondary payer.
Preventative Measures
Regularly review and update patient insurance information to ensure accuracy.
Disable settings like "Auto Set Billing Status" if they conflict with your billing workflow.
Use adjustment master rules to manage specific payer scenarios effectively.