What information can I get from the Pre-tax Claims Transaction Report?

How do I calculate approval rate from this report?

1. Filter out claims where ‘Parent Claim ID’ is populated to exclude duplicate claims. Child claims are submitted by the system, not by the member.
2. Calculate the sum of all claims (ex: 100)
3. Calculate the sum of ‘Claim Status’ for ‘approved’, ‘reimbursed’, ‘in progress’, and ‘completed’ status types (ex: 15+22+7+16 = 60)
4. Divide the ‘Claim Status’ sum by the sum of all claims (ex: 60/100 = 0.6)

What does it mean when "Amount Rejected" is greater than $0?

• The claim are either partially or completely rejected
• If a claim is partially approved, the ‘Claim Status’ would be ‘approved’, ‘reimbursed’, ‘in progress’, or ‘completed’
• Amount Approved + Amount Rejected = Amount Requested

When is approval rate populated?

• When a claim is ‘Approved’
• When a claim is ‘In progress’
• When a claim is ‘Overpaid’
• In some cases, when a claim is ‘Rejected’ because it was initially approved but the status changed to rejected

What are overpaid claims and how will they display in the report?

A claim can be marked as overpaid if it’s been reimbursed but later found to be ineligible.

If the entire reimbursement is determined to be ineligible

• • The ‘Amount Rejected’ will equal the ‘Amount Requested’
  • The ‘Amount Approved’ will equal $0
  • The ‘Amount Offset’ will be updated to a negative amount and it will reflect the original approved amount
  • The ‘Amount to be Reimbursed’, which is Amount Approved - Amount Offset, will remain the amount the member was reimbursed

If only a partial amount is overpaid

• • The ‘Amount Rejected’ will be the amount overpaid + the original amount rejected
  • The ‘Amount Approved’ will be updated to the original approved amount - amount overpaid
  • The ‘Amount Offset’ will be updated to a negative amount and it will reflect the amount overpaid
  • The ‘Amount to be Reimbursed’, which is Amount Approved - Amount Offset, will remain the amount the member was reimbursed

If there are claims submitted and approved after the overpaid claim was adjudicated, and those new claims partially cover the balance due

• • The ‘Amount Paid Back’ will equal the total amount that has been offset by the new approved claims
  • The Status will remain overpaid

If there are claims submitted and approved after the overpaid claim was adjudicated, and those new claims completely cover the balance due

• • The ‘Amount Paid Back’ will equal the total amount that has been offset by the new approved claims
  • The ‘Amount Paid Back’ will be a positive amount of the Amount Offset
  • The Status will be updated to Reimbursed

Scenario: A new claim fully offsets an overpaid amount

1. • A member submits a claim for $26.70.

   • The claim is approved and reimbursed.

   • Later, the claim status changes to "Rejected", creating an overpaid amount of $26.70.

   • A new claim is submitted and approved, completely covering the balance due.

Breakdown of Amounts:

• • Overpaid Amount: $26.70

  • Amount Approved (new claim): $26.70

  • Amount Offset: - $26.70 (offset by the new claim)

  • Amount to be Reimbursed: $26.70

  • Amount Paid Back: $26.70 (displayed as a positive value since the balance due was fully offset by another approved claim)

This example illustrates how a newly approved claim can automatically cover a previously overpaid amount, effectively resolving the balance.