Crossover Claims

Jump to Section:

Crossover Claims

Crossover claims will now be handled natively within the system rather than the process of manually adjusting the claim.

Fusion will automatically link a remit’s adjudication to the correct claim instance based on a segment the payer defines in the 835 files. If a relevant value for this segment isn’t present in a particular 835 file, the system will fall back to the existing method of claim matching for that remit. This will also apply to non-crossover claims.

We have laid out a few common scenarios regarding crossover claims and managing them.  You will see a brief description of the scenario and the new, easier steps you will see in the system.

In this scenario, we will be looking at finalizing a claim that the payer has forwarded.  In this scenario:

• A primary claim has been submitted
• The primary payer sent a remit to the system and forwarded to claim to the secondary payer
• Biller finalizes primary claim to secondary.
• You are now prompted to move the new claim instance to the Accepted status.
  

Check out our article, Post a Manual Remit for more on how to post a manual remit.

In this scenario, we will be looking at finalizing a claim when the next instance has a remit.  In this scenario:

• The primary claim has been submitted
• The primary payer sent a remit to the system and forwarded the claim to the second payer
• The secondary payer sent a remit.

1. Biller finalizes the primary claim to secondary
2. The new claim instance will be moved directly to the Paid or Not Paid status.
   

Check out our article Post a Manual Remit for more on how to post a manual remit.

In this scenario, we will be looking at deleting a claim instance with adjudications.  In this scenario:

• The primary claim has a remit and has been finalized.
• Adjudications are linked to the secondary claim.

1. If the biller needs to modify adjustments linked to the primary claim
2. You can now delete the secondary claim without deleting the secondary adjudications.
   Add pictures?

Check out our article Delete a Claim for more on how to delete a claim.

It's now possible for adjudication to be linked to a secondary claim when the current claim instance is still primary.

• If you try to finalize a claim from a remit for a future claim instance, a warning will appear allowing you to finalize the remaining claims or not.
  

A Couple of new history items

• • A "Payer forwarded claim" history item is added when a remit is linked to a claim where the payer indicated they forwarded the claim to the next payer.
  • A "Remit for Secondary already exists" history item is added when finalizing to a claim instance that already has adjudications.

[Back to Top]