Claim matching is a crucial process within Rivet that connects claims to remittances (remits), facilitating accurate pricing, underpayment detection, recovery identification, and precise representation of complex claim structures. This process occurs at three distinct levels: the claim level, the claim payer level, and the line item level. Each level plays a vital role in ensuring that claims and remittances are accurately matched.
1. Claim Level
Claim Level Matching occurs when importing claim and remit files into your account. This matching is based on 2 factors: the patient account number (sometimes called “claim IDˮ in other systems) and the service date.
Occasionally, we have to make very small adjustments to the patient account number to serve claim matching, most often removing a trailing -01 or -02 from the patient account number to ensure the claims and remits match.
2. Claim Payer Level
Matching at the Claim payer level also occurs based on two factors: the payer sequence (primary, secondary, etc.) defined on the imported claims data and the payer name, after being mapped inside Rivet.
These matches are reflected when viewing a claim and seeing the groupings of transactions by payer and sequence (sometimes referred to as Coordination of Benefits). Correct mapping of payers within Rivet is essential to avoid mismatches, especially in scenarios involving primary and secondary payers.
3. Line Item Level
Line Item Level Matching is more complex than the other levels, due to the high variance in information on line items across claims and remits. Where the other layers of matching happen on a straightforward basis using raw data, Line Item Level matching occurs by taking all the information from line items on a claim or remit and running them through a complicated algorithm designed to evaluate and score potential matches. The algorithm considers the line item control number, line number, code, modifier, quantity, and other values. Based on this scoring, line items are then connected within our database.
For further assistance or inquiries, feel free to contact our support team via chat or email at support@rivethealth.com.
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