QA Review Quick Guide
- Tracy Archuleta
The QA Review Functionality is a mechanism by which paid services can be recouped. Here are the following stages involved in the QA review process:
Stages | Definition |
|---|---|
Stage 1: Reviewable | All paid services (encounters and claims) that can be flagged for recoupment. |
Stage 2: Flagged | All paid services that have been flagged for recoupment by either the Lead Agency or the Vendor. |
Stage 2a: Flagged by File | Services flagged for recoupment through a file of records identified by Lead Agency Analysis. |
Stage 3: Confirmed for Recoupment | All paid services that have been flagged for recoupment and agreed to be recouped by both Parties or identified for recoupment in the first place by the Vendor. |
Stage 4: Repayment Process | Once services have been identified for recoupment, it is necessary for Falling Colors to get the funding back from the Vendor. This can be done through the reduction of payment against a future invoice or by the Vendor sending a check. Both can be done in increments. |
Stage 4a: Confrimed for Refund | Services that have been repaid by the Vendor and identified as needing to be refunded to the Vendor. |
Boxing Ring
Lead Agency must contact and inform the Vendor in order to start the clock for recoupment.
Lead Agency is required to enter when and who they contacted for records to be available for a Vendor to review.
Vendors can choose to accept the recoupment, in which case they agree to make repayment via future payment offsets or by sending Falling Colors a check. (Stage 4)
Vendors can petition records flagged for recoupment and attach supporting documentation to accommodate the petition.
After a petition is made, the Lead Agency can request clarification on the petition.
Lead Agency may or may not require the Vendor to include supporting documentation as part of clarification.
Vendors and Lead Agencies can go back-and-forth between 'Clarification Required' and 'Clarification Provided' as many times as necessary.
Note: Lead Agency can also choose at any time to 'force' a recoupment or accept the petition.
Actions completed by either side during the negotiation result in a deadline being set for the other side to respond.
Icon | Definition |
|---|---|
 | Record has been flagged for Recoupment by the Lead Agency |
 | Clarification of Petition has been provided to the Lead Agency by the Vendor |
Clarification of Petition Requested by the Lead Agency | |
Recoupment has been Confirmed by the Vendor | |
Recoupment has been Released by the Lead Agency |
Sort and Search Bar
Records Flagged for QA review are ordered inside groups with the nearest auto-recoupment deadline on top.
Click a record to see the details in the Record Status, Record Details, and Record History sections.
When the provider box is selected, the provider name will display along with the number of records in each “Flagged” and “Clarification Required” category
Providers with multiple locations can select a specific location to view. Each location will display the “Flagged” and “Clarification Required” information.
Dashboard
The Record Status section for each record will display the number of days remaining for your action to be completed before the record is either auto-recouped or auto-released.
To accept record(s) marked for recoupment:
The status icon for the record will change from the orange triangle to a handshake icon when the record is accepted.
To petition record(s) marked for recoupment:
The status icon for the record will change from the organ triangle to a petition icon.
To submit clarification on record(s) marked for recoupment:
The status icon for the record will change from the question mark icon to a petition icon.
To export records(s) marked for recoupment to Excel:
Click the record(s) in the checkmark column to highlight them.
You can select ALL records in a group by clicking on the checkmark in the group header.
Click Export to CSV.
An Excel CSV file will be displayed.
Additional QA Review User Information:
Note: You can change the number of Records Per Page displayed based on your preference. Depending on the number of entries in the Record History, the Number of Pages will increase or decrease accordingly.