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Claim processing reports

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Updated on August 31, 2021

Smart Claims Engine provides baseline reporting on claims processing. These reports are available by selecting the Claims processing category from the dropdown on the reports screen.

The reports listed with denoted by an asterisk (*) are also displayed in the Claims manager portal and provide weekly, monthly, and yearly breakdowns.

Available claims processing reports include:

Report nameTypeDescription
Average Claim Processing CountChartCount of claims processed since yesterday, broken down by status.
*Average Claim Processing Count - MonthChartCount of claims processed this month, broken down by status.
*Average Claim Processing Count - WeekListCount of claims processed in the past 7 days, broken down by status.
*Average Claim Processing Count - YearChartCount of claims processed this year, broken down by status.
Average Claim Processing TimeChartDisplays average processing time of claims resolved in the last 7 days.
Average Claim Processing Time - 3 Hour IncrementsListDisplays resolution time in minutes, status, claim type, billing provider ID, payer ID, and contract ID; broken down into 3 hour increments.
Average Claim Processing Time -1 Hour IncrementsChartDisplays average processing time of claims resolved in the last 7 days, broken down by hour
Average Claim Processing Time -1 Hour IncrementsListDisplays resolution time in minutes, status, claim type, billing provider ID, payer ID, and contract ID; broken down into 1 hour increments.
Backlog CounterSummaryDisplays all unresolved claims by status, as well as a count of those claims.
Claims - By Status Last 7 daysListLists all claims processed in the last 7 days by status.
Claims - Last 7 DaysListLists claims that have been updated in the last 7 days
*Claims BacklogChartDisplays all unresolved claims from the last 7 days, with claim counts per day.
Claims exceeded SLA daysListLists claims on hold with a hold SLA assigned
Claims Test - Last 7 DaysListList of test claims processed in the last 7 days
Claims to be PaidListLists claims approved for payment or cancelled
Encounter process - Member contractSummaryTotal number of encounters processed per member
Event Code/ Module Fallout Details ReportListSuspended claims received today and in the last 7 days
Event Code/Module Fallout Summary ReportSummaryAll suspended claims broken down by age and module
Event Group ClaimsListList of claims associated to event groups
*First Pass RateChartDisplays first pass indicator for claims resolved in the last 7 days, broken down by claim type
*First Pass Rate - By MonthChart Displays first pass indicator for the month, broken down by claim type
*First Pass Rate - By YearChartDisplays first pass indicator for claims resolved this calendar year.
First Pass Rate - Overall Last 60 daysSummaryDisplays first pass indicator (Y/N) for claims resolved in the last 60 days.
IBNRSummaryDisplays Pending-Approved claims broken down by status
IBNR - ProviderSummaryDisplays IBNR by billing provider tax identification number
LPI ReportSummaryLists claims incurring late payment interest by claim type
Mass Adjustment Process - By ProviderListList of sequenced mass adjustment jobs with breakdown by provider
Mass Adjustment Process - By SubscriberListList of sequenced mass adjustment jobs with breakdown by subscriber
Operator PerformanceSummarySummary of tasks by operator, including processing time and duration
Operator Statistics ManagerChartSummary of operator resolved work for the current week
Operator Statistics ManagerSummaryDaily summary of operator resolved work
Process TimeChartProcess time per claim type for the past 7 days
Provider Claim AnalysisSummarySummary of claims approved in the last 7 days by provider tax identification number
Test claimsListTest claims updated in the last 7 days
Turn Around TimeSummaryClaim turnaround time for the last 7 days by provider
Turn around timeChartClaim turnaround time for yesterday by claim type

Additionally, the Claims manager portal displays the following reports:

Report nameTypeDescription
Average days on handListDisplays the average days on hand and the average productivity (average number of claims per day per examiner) of claims examiners.
Average resolution time in daysChartDisplays the average resolution time in days for the time period selected.
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