How to Correct Common Claim Errors at the Source in ElderSuite

📝 Overview

When a claim has the wrong date of birth, date of service, pay rate, or diagnosis, the fix starts at the source those values come from, not on the claim alone. Correct the source record, set the claim's Claim Status back to Pending, run Scrub & Fix, and send the claim with Process Claims. That work runs through the Claim Center. See the ElderSuite Claim Center Overview and How to Scrub Claims in ElderSuite. If the claim was already accepted or adjudicated, see How to Adjust a Submitted Claim in ElderSuite.

⚙ How It Works

Fix the Source and Set the Claim Back to Pending

A claim in ElderSuite belongs to an attendance record. Adding attendance creates the claim as Pending. Other values come from the client record, Claim Setup, or the payment type. Scrub & Fix copies from the client record onto Pending claims: it fills missing values and refreshes the pay rate.

Set the claim back to Pending before you change attendance times or run Scrub & Fix. A single claim's status can be set back to Pending on the claim itself, and several at once from Reconcile Claims. See How to Edit a Claim on the Health Insurance Claim Form in ElderSuite and How to Reconcile Claims in ElderSuite.

After the error flag is clear, Save & Close and send the claim with Process Claims, which picks up Pending claims that are not flagged with an error. See How to Process Claims in ElderSuite.

Wrong Date of Birth

The date of birth comes from the client record, on the Contact Info tab in Date of Birth. It cannot be edited on the claim or in Claim Setup. The claim keeps no copy of it: ElderSuite reads the date of birth from the client record each time a claim is sent or printed, so a correction is on every claim sent after the save.

Claims already sent went out with the old date. Set those claims back to Pending, run Scrub & Fix, and send them again with Process Claims. Scrub & Fix checks the date of birth on the client record and does not write it to the claim. If the date of birth on the client record is missing or unreadable, Scrub & Fix flags the claim and cannot fix it, which means the client record still needs the correction.

Wrong Date of Service

The Date(s) of Service in Box 24A cannot be changed from the claim. It comes from the attendance record.

Set the affected claim back to Pending first. Attendance times can be entered while that day's attendance is still Pending or has no status yet. If the times cannot be edited, see How to Unlock Attendance Times in ElderSuite.

In Attendance & Transportation Records, clearing that client's times on the wrong date and saving removes that attendance record (there is no Delete button) and its claim, and entering times on the right date creates a new attendance record with a new Pending claim. If a meal was recorded for that client on the wrong date, the attendance record stays, with a Pending claim of 0 units, until the meal is removed in the Nutrition Center as well. Run Scrub & Fix and send the new claim with Process Claims. See How to Record Attendance and Transportation Times in ElderSuite. If the original claim was already accepted or adjudicated, use the adjustment Guide linked above.

Pay Rate Set Per Day Instead of Per Unit

When claims were billed at a flat daily rate and the payer reimburses by unit of service, the fix is on the payment type: Pay Rate per Unit, with Unit Definitions for how many hours make each unit. Open Manage Payment Types from Related Activities on the Client Center or the Claim Center.

After Save & Close, the Update Payment Settings prompt may appear with the text “ElderSuite detected changes in a Pay Rate. ElderSuite can apply these changes globally to each client currently assigned this Payment Type.” Yes writes the new pay rate to every client assigned that payment type and confirms with a Changes Applied message. No leaves existing clients on their current rate. The prompt appears only when the pay rate changed on an existing payment type and the Client List is open with at least one client listed. If the prompt does not appear, no client rate changed. The change to per reaches those clients at the save either way, so a client left on the old daily rate would be billed that rate for each unit. See How to Manage Payment Types in ElderSuite and How to Update Payment Settings in ElderSuite.

For claims already created, set them back to Pending and, in Attendance & Transportation Records, clear and re-enter that client's times so units and the amount recalculate. Run Scrub & Fix and send the claims with Process Claims.

Wrong Diagnosis Code

The diagnosis that billing uses lives in two places: Box 21 on the claim, and Box 21 in the client's Claim Setup. For one existing claim, correct the Box 21 diagnosis code on the claim, set the claim back to Pending, run Scrub & Fix, and send it with Process Claims. Claim Setup changes apply to claims built after the change; they do not update claims already created. For later claims, correct Box 21 in Claim Setup. See How to Use Claim Setup in ElderSuite.

A diagnosis recorded in the Nursing Center is clinical documentation and does not reach claims. If the Nursing Center record also needs to be updated, see How to Add Client Diagnoses in ElderSuite.

Modifier Required or Rejected

If a payer requires or rejects a modifier, start with the client's Claim Setup, which supplies the modifier for new claims. A change there does not reach claims already created. Correct the modifier on each existing claim, set the claim back to Pending, and run Scrub & Fix to confirm the error flag is clear.

⚠ Scrub & Fix Does Not Recalculate a Non-Zero Amount

Scrub & Fix leaves a non-zero amount as it is, even when it refreshes the pay rate. A rate correction needs the attendance times re-entered so units and the amount recalculate.

💡 Need More Help?

For step-by-step instructions, click Ask Eddie from within ElderSuite.