How Auto Reconcile Updates Claim Statuses in ElderSuite

Auto Reconcile helps ElderSuite users update claim information using data contained in clearinghouse reports. Instead of manually reviewing and updating every matching record, Auto Reconcile processes the report, finds the corresponding ElderSuite records, and applies eligible claim-status updates.

This can reduce repetitive data entry while providing a clear summary of the records that were updated, skipped, or could not be processed.

Where to Find Auto Reconcile

To begin, go to:

Claim Center → View Reports

Open the appropriate clearinghouse report in the Report Viewer, review its contents, and select Auto Reconcile.

Always verify that you have opened the correct report before starting. Auto Reconcile uses the information displayed in that report to locate and update matching ElderSuite records.

What Information Does Auto Reconcile Require?

Before processing begins, ElderSuite confirms that report data is available and checks for the required columns.

The report must contain:

• Patient ID
• Service Date
• Status

ElderSuite can also capture the Claim Number when that information is included in the report.

If the required information is missing, Auto Reconcile may be unable to process some or all of the report. ElderSuite displays the number of records that will be processed before making any updates.

How Records Are Matched

For each row in the clearinghouse report, ElderSuite reads the:

• Patient ID
• Service date
• Reported claim status
• Claim number, when available

ElderSuite then searches for a matching attendance record using the Patient ID and Service Date. The Patient ID from the report is cross-referenced with the client’s insurance ID in ElderSuite.

Both pieces of information must identify the appropriate record. A missing or mismatched Patient ID or service date can prevent the record from being reconciled.

What Happens When a Match Is Found?

When ElderSuite finds an eligible matching record, Auto Reconcile can:

• Update the claim status using the status reported by the clearinghouse
• Add or update the claim number when one is provided
• Create an audit note documenting the change

The audit note helps preserve a history of the automated update.

Finding a matching record does not necessarily mean its status will be changed. ElderSuite also applies status-transition rules to prevent an existing final status from being replaced by an inappropriate status.

Claim Status Transition Rules

Auto Reconcile evaluates the current ElderSuite status before applying the status found in the report.

The primary transition rules include:

• Paid: Treated as a final status and cannot be changed by Auto Reconcile.
• Denied: Treated as a final status and cannot be changed by Auto Reconcile.
• Rejected: Treated as a final status and cannot be changed by Auto Reconcile.
• Accepted: Can transition to Paid or Denied.
• Acknowledged: Can transition to Accepted, Rejected, Denied, or Paid.
• Submitted or Pending: Can transition to any valid status received from the report.

These rules help prevent older or less complete clearinghouse information from overwriting a more conclusive claim outcome.

Reviewing the Completion Summary

After processing is complete, ElderSuite displays a summary showing:

• The total number of records processed
• The number of records successfully updated
• The number of records skipped
• The number of records that failed to update

Review this summary after every reconciliation. A completed process does not necessarily mean that every row was updated.

Why Might a Record Be Skipped?

A record may be skipped when:

• The Patient ID is missing
• The Patient ID does not match a client insurance ID
• The service date is missing
• The service date does not match an attendance record
• The claim status is missing
• The existing claim status does not permit the requested transition
• No corresponding ElderSuite record can be found

Skipped records should be reviewed individually. Compare the clearinghouse report with the client’s claim and insurance information in ElderSuite to identify the mismatch.

Recommended Auto Reconcile Workflow

For the best results:

1. Go to Claim Center → View Reports.
2. Open the correct clearinghouse report.
3. Review the report before processing it.
4. Confirm that the report contains Patient ID, Service Date, and Status information.
5. Select Auto Reconcile.
6. Review the number of records ElderSuite is preparing to process.
7. Allow the reconciliation to finish.
8. Review the completion summary.
9. Investigate skipped or failed records individually.

Auto Reconcile is designed to make claim tracking more efficient, but it does not replace reviewing clearinghouse reports. The report remains an important source of information about claim acceptance, rejection, denial, payment, and other processing activity.

If you need help interpreting a report or determining why a record was skipped, use Ask Eddie or contact ElderSuite Support.

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