Required Areas and How to fix Holds

After you have generated claims, you receive a pop up box that indicates the action on how many lines are ready to be submitted, and how many lines were put on HOLD

After selecting the OK at the bottom right screen, you can fetch the holds from the same Claims Submission Section to investigate the issues

Using the Search by Date of Service, and enter the dates in the From and To fields, put the Status as HOLD and then hit the Search Tab, it will pull all the lines that were placed on hold

Then you can view the message in the same screen, or use the bottom scroll bar to slide it over to the right

Under the Message column section, it provides the reason the line was placed on hold that will not allow the system to create a claim ID until the issue has been resolved

To open the patient’s chart, you can click on the MRI# and it will open up like a hyperlink and allow you to make the necessary corrections based off the message posted in the claim submission screen

Here are a few common issues / messages that will cause claims to get placed on hold

The diagnosis Code1 is required, The diagnosis Pointer is required
The patient Individual Rel Code is required - or - The patient Date of Birth is required - or - The subscriber DOB is required
The patient Address is required, The patient City is required, The patient State is required, The patient Zip is required
The patient Gender Code is required - or - The subscriber Gender Code is required
The Insurance Provider Name is required
The Insurance Provider Payer Id is required
The Insurance Provider Address is required, City, State,and Zip is required
The service Facility Npi is required - or - The service Facility Name, Address, City, State, Zip, and Phone is required
The Insurance Authorization Number is required
The service was provided on a date after the discharge date

These are things to review and correct the issues to allow the service to generate the Claim ID

1st. Example:

The diagnosis Code1 is required

In the patient chart, on the top right, you will see the box that holds the warnings, and the Diagnosis.

To access this, select the blue Menu drop down to the bottom and click on the appropriate option

2nd Example:

The patient Individual Rel Code is required
The patient Address is required, The patient City is required, The patient State is required, The patient Zip is required
The patient Gender Code is required - or - The subscriber Gender Code is required

To access this, select the blue Menu drop down to the bottom and click on the appropriate option = Primary Insurance, in this section you can resolve issues 1. Pt relationship Code, 2. Pt Address, & 3. Gender Code

Once this has been selected, hit the blue OK button to save.

3rd Example:

The Insurance Provider Name is required
The Insurance Provider Payer Id is required
The Insurance Provider Address is required, City, State,and Zip is required

This is a 2 part confirmation process to check 2 separate area's:

1st, to access this, select the blue Menu drop down to the bottom and click on the appropriate option = Primary Insurance,

Then scroll down to the Medical Insurance Information section and check the Insurance Provider information is entered correctly, then select ok to save

Now go into the Billing Tab on the left side tool bar and select the Insurance Providers tab

Now you can see the list of all the Insurance Providers, and use the top Search option to locate a specific payer, then select the name in blue is the link to open that payer details

Here you can check to make sure that all these highlighted sections have the correct information loaded, then select the blue update tab at the bottom to save

4th Example:

The service Facility NPI is required - or - The service Facility Name, Address, City, State, Zip, and Phone is required

This will require you to go back to the far left side tool bar under the SUNWAVE Logo, click on the Practice Setup to open the drop down, then click on the Service Facilities Tab to open it up

Once you have the appropriate service facility selected, it will open with the demographics section

Here is where you can enter, or confirm all information is accurate, then select Update in the lower right corner to save

5th Example:

The Insurance Authorization Number is required

When you are in the patients chart, go to the Insurance Tab and use the drop down, select

Insurance Authorizations : Once in the Authorizations section click on the “+” icon to add an authorization line, you will be prompted to choose a service that you are obtaining authorization for

Fill in the necessary items, Call Date, Visits, Authorization From and Until Date, Next Review, Authorization Code, UR Reviewer and any additional comments that may be useful.

Please note if an authorization code is not placed in the system and a biller attempts to bill for a service that requires the authorization it will place the claims on hold, and a claim ID # will NOT be created when you generate claims.

5th Example:

The service was provided on a date after the discharge datepatie

When you are in the patients chart, on the Face Sheet you will see the details for the Discharge

Sometimes, a patient has an authorization on file, and a service was on the census, claims were generated but then the patients gets retro-discharged. To view the details on when the discharge was completed, hit the Pen & Pad Icon at the Level of Care tab to open it.

This shows you the Change History, and provides info on when the discharge was entered, the discharge time and the type.

Keep in mind after all of the corrections have been made to resolve the hold issues, you will need to refresh, and hit Re-Generate status allows re-scrubbing for a resubmission after necessary corrections