Creating Audits With Claims Connect

Your organization has acquired an integration tool named Claims Connect, facilitating seamless connectivity between Audit Manager and your organizational systems. This tool enables the regular importation of claims data into Audit Manager. Below, you'll find instructions for retrieving your claims, selecting  claims for auditing, and finally, creating audits.

Using The Search Fields

Begin and End Date Range: The date range for the search is automatically defaulted to the last three months based on the current date.

Audit Project: Select the project for which you are creating audits.  This is the only required field.

Practice:  You can select one or more practice(s), locations or divisions to search for in the Claims Connect data.

Provider:  From this list of providers, you can select one or more providers in one search.

Specialty:  This a list of specialties as provided by your organization.  This may be based on specialties defined by taxonomy or just a general list of specialties.   You can select one or more specialties to search for at the same time.

Payer: This list is the payers that your organization has sent to Claims Connect.  You can select one or more payers to search for at the same time.

CPT/HCPCS Codes:  You can enter individual procedure code(s), range(s) of procedure code(s), or a combination of individual and ranges of code(s). The key is to format your entry correctly. Separate individual codes or ranges of code with a coma.  Identify ranges with a hyphen between the first and last code of the range.  Do not put spaces between the entries.  A The individual code or the first and last code in the range must be valid codes. If they are not valid codes for you will get an error message.  This is a sample of how the codes should be entered:  99201-99215,99381-99387,99407,99408.

Modifiers: Enter modifiers you want find claims for. Separate individual modifiers with commas but no spaces.  You cannot enter ranges for modifiers.

Diagnosis Codes:  Like CPT/HCPCS you can search for individual codes, ranges of codes or a combination of ranges and individual codes.

Available Records

The number displayed in # Available Records is the number of claims that were returned by the search.  Remember this count includes the rows within the data that are part of a claim but it not the exact procedure that was searched for.

Understanding The Data In List Section

Based on previous user requests, all the data for a claim is returned in the search if any of the rows meet any of the search criteria.  This allows users to quickly understand the combination of services performed to determine if the claim has the scenarios they want to audit.

Claims have multiple rows in the list IF there are multiple dates of service on the same claim.  If a claim has multiple dates of service, there will be a roweach date of service.   The rows for a date of service will always be grouped together.

Above the list table there is a magnifying glass where you can enter text to search within the table. The system will look for matching text in the Patient Name, Patient ID, POS, DOB or Gender columns.

Creating Audits

There are two methods to create an audit:  1) random, or 2) selected.  Each has slightly different nuances  you need to understand.

Random Audits

1. Modify date ranges if needed.
2. Select the project to which the audit will be assigned.
3. If desired, select auditors and/or QA reviewers.
4. Enter filter criteria as desired.
5. Enter the number of random records you want included for each provider.
6. Click on Create Audit.
7. The audit will be created and displayed in the appropriate queue.
   • If you do not select an auditor the audit will be found in the Pending Assignments queue.
   • If you select an auditor the audit will be found in the auditors Work Queue.
   • The same logic applies to QA Reviewer, if not selected at the time of audit creation, the audit will go to pending assignments once the initial audit is completed.

 Selected Audits

1. Modify date ranges if needed.
2. Select the project to which the audit will be assigned.
3. If desired, select auditors and/or QA reviewers.
4. Enter filter criteria as desired.
5. Leave the number of random records blank.
6. Click on Search to view the records that meet your search criteria.
7. Review the records that meet your search criteria.
   • To add a claim to the audit, click on the box on the left of the row.
   • Use the box above the select column to either Select All or Unselect All.   You can check or uncheck audits so that only the rows you want in the audit are selected.
8. Click on Create Audit.
9. The audit will be created and displayed in the appropriate queue.
   • If you do not select an auditor the audit will be found in the Pending Assignments queue.
   • If you select an auditor the audit will be found in the auditors Work Queue.
   • The same logic applies to QA Reviewer, if not selected at the time of audit creation, the audit will go to pending assignments once the initial audit is completed.
   • If you select an auditor the audit will be found in the auditors Work Queue.

 Notes on Creating Audits

• If you enter a random number of records and select rows in the list and click on Create Audit only the selected the audits will be included in the audit.