Rank Based KPI

Rank KPI Workqueue assigns a rank automatically to open insurance claims based on defined payer thresholds and time left factor for prioritization of claims follow-up.  Like Collection Manager, claims get pulled to the queue and are assigned to the user’s worklist for follow-up and action.

The ranking is driven by predefined payer thresholds saved in the insurance master and on “Time Left” calculated using either the remit date (for denied claims or having a remit date) or date of service (for the claims where no response received).

1. The first step for the rank assignment is to add the date of service time limit (“Untimely Filing Limit”) and the remit time limit (“Response Limit Threshold”) in the Insurance Master screen.  “Time Left” is then calculated by the system using the formula below:

a) DOS Time Left= DOS Time Limit* – (Today’s Date – Date of Service)

b) Remit Time Left= Remit Time Limit** – (Today’s Date – Payment Date).

*DOS Time Limit: – Enter the days in “Untimely Filing Limit” in Insurance Company Master. If no value is entered in the field, taken as 45 days.

**Remit Time Limit: – Enter the days in “Response Limit Threshold” in Insurance Company Master. If no value is entered in the field, taken as 30 days.

2.  Rank is determined by the “Time Left” factor. There are four criteria for obtaining the claim rank and the final ranking is obtained after determining all the four or the applicable rankings.

A. DOS Time Left Rank – For all open claims.

B. Claim Rank – For all submitted claims.

C. Payment Rank – Claims that have a payment/denial.

D. Remit Time Left Rank – Claims that have a payment/denial.

Final Ranking of Claims

1. Table 1 explains the ranking mechanism and the priorities assigned for the ranking. Claims falling in Rank 5 have the highest priority and Rank 1 the lowest.

 

Claim Status Rank Calculation
For Unsubmitted Claims
DOS Time left Rank Rank 5-DOS Time Left<=0

Rank 4-DOS Time Left>0 & DOS Time Left<=15

For Submitted Claims
DOS Time left Rank Rank 5-DOS Time Left<=0

Rank 4-DOS Time Left>0 & DOS Time Left<=15

Claim Rank Rank 3– Claim Age>50

Rank 2-Claim Age>=40 & Claim Age <=50

Rank 1-Claim Age<40

For Remit/Payment Received Claims
Remit Time Left Rank Rank 5– Time left<=0 days

Rank 4– Time left>0 & Time Left<=15

Payment Rank Rank 3– Payment Aging>50

Rank 2-Payment Aging>=40 & Payment Aging<=50

Rank 1-Payment Aging<40

Table 1

2. As shown in Table 1, for claims with payments/remits, the Remit Time Left Rank is used for determining the rank and the second in line that is used is Payment Rank.

For the submitted claims and where no payments were made, the DOS Time Left is primarily used for determining the rank (Note that, Remit Time Left rank and Payment rank are not available in these types of scenarios as payment/denial is not received for them).

3. For the secondary claims, the primary’s remit date is used for determining the rank, and similarly for the tertiary claims, the secondary’s remit date is used.

Illustration

In Each Case listed below Assume Current day: 3/3/2022

DOS Claim Date Payment Date DOS Time Limit(Untimely filing Limit) Remit Time Limit(Response limit Threshold) Rank Assigned
11/15/2021 12/19/2021 120 4
12/3/2020 11/10/2021 12/13/2021 120 15 5
2/24/2022 2/24/2022  – 120 1
10/22/2021 10/26/2021  – 210 3
2/2/2022 2/2/2022 2/12/2022 120 90 1
10/10/2021 11/10/2021 11/15/2021 120 120 4