NikoHealth automates the processing and posting of payer remittances according to the claim adjustment reason codes (CARC) posted against a service line of an invoice.
In the case where you would like to assign custom actions to how CARC codes are treated by default in the system, you can create custom claim adjustment rules.
To create a rule go to: management/billing/claim adjustment rules
Here you will see all default rules defined in the system. You can edit an existing rule or create a new rule by clicking on the blue + button on the upper right hand corner.
Creating a Rule
Payer: Select a specific payer or if left blank the rule will be applied for all payers.
Payer Level: Indicate a payer level or select all.
Group: Select a group or if left blank the rule will be applied for all groups.
Action: Select the action for this rule:
Adjust Balance : This will adjust the balance on the service line by the $ amount indicated on the CARC code posted.
Patient Responsibility: This will be treated as a patient responsibility on the service line by the $ amount indicated on the CARC code posted.
Ignore Adjustment: This will be ignored and will not be treated as either an adjustment or patient responsibility.
Reason: Select the claim adjustment reason code for this rule.
Description: Free text for internal reference.