Rank Based KPI
Rank KPI Workqueue assigns a rank automatically to open insurance claims based on defined payer thresholds and the time left factor for prioritizing claim follow-up. Like Collection Manager, claims get pulled to the queue and 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 claims where no response was 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, it is taken as 45 days.
**Remit Time Limit: Enter the days in the “Response Limit Threshold” in Insurance Company Master. If no value is entered in the field, it is taken as 30 days.
Note: Users can set default threshold days for the “Untimely Filing Limit” and “Response Limit Threshold” parameters of the Ranking Work Queue from the “Billing Options” screen.
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 four or the applicable rankings.
A. DOS Time Left Rank: For all open claims.
B. Claim Rank: For all submitted claims.
C. Payment Rank: For claims that have a payment or denial.
D. Remit Time Left Rank: For claims that have a payment or 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 those falling in Rank 1 have the lowest.
| Claim Status | Rank Calculation | ||||
| For Unsubmitted Claims |
|
||||
| For Submitted Claims |
|
||||
| For Remit/Payment Received Claims |
|
Table 1
2. As shown in Table 1, for claims with payments or remits, the Remit Time Left Rank is used for determining the rank, and the second rank that is used is the 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 the Remit Time Left rank and Payment rank are not available in these types of scenarios as payment or 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 |