1. What exactly are exclusions?
Rivet will always consider a line item a denial when it meets either of the following criteria:
A line item with a charged amount greater than $0.01 and an allowed amount of $0.00.
A line item with a charged amount greater than $0.01, $0.00 in payer payments, and $0.00 in patient responsibility.
If you would like to add additional restrictions to the above definition, you can build exclusion rules.
2. What will happen if I build an exclusion rule?
1. Building an exclusion rule will remove any denials that match that rule from your denials worklist.
2. Denials that match that rule will automatically change from a Denied status to a Paid status in Rivet’s mapping rules.
3. Denials that have been excluded will no longer count toward your $ Denied and % Line Items Denied in Claims Analytics.
Criteria Options:
Select specific filters by using the drop down arrows to build your exclusion.
3. Exclusion rule in use example
In the below sequence, you'll see we build an exclusion rule for Adjustment Code is CO-45.
What this means is that we will exclude all denied line items with a charged amount > $0.01, an allowed amount of $0.00 or $0.00 in payer payments and patient responsibility, with a single adjustment code equal to CO-45.
If you consider line items that have had the complete charged amount adjusted off with a CO-45 adjustment code, you would NOT want to build an exclusion rule for this.
But if your practice does not consider any line items with just a CO-45 adjustment code to be denials - even if the full dollar amount has been adjusted off - then you would want to build this exclusion rule.
4. Building an exclusion rule
Navigate to the General tab of your Denials Settings by clicking on the Account Name and then Account settings
Then click on Denials on the menu on the left.
Click Create Exclusion.
Select your Exclusion rule criteria.
Click Create exclusion. Exclusions apply to historical as well as future denials in your account.
If you have any additional questions about the Claim Resolution feel free to chat in or email at support@rivethealth.com.
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