Adjustments to Paid Claims in ProviderOne
The department is in the process of making adjustments to some paid claims in ProviderOne where incorrect resident participation (client responsibility-CR) amounts may have been deducted from paid claims.
In April 2024 the department made a change to the way resident participation was applied to authorizations. They were no longer changing the participation amount if that amount was reduced after the month had already started. As a result, there are instances where claims were submitted, and the incorrect amount of participation was deducted from the paid claims.
Since the department became aware of the issue, they have been working on a solution to ensure authorizations are updated in a more timely manner when participation amounts are reduced after the month has started. Beginning September 2024 DSHS will review a weekly CR report and will manually update affected social service authorizations. In addition to improving the process moving forward they have been working on identifying affected claims and updating current records where too much CR was applied. Once identified, they will initiate an adjustment for all paid claims associated to a resident and month of service where there is an indication that excess CR was applied to the authorization. The expected outcome for most of the adjusted claims will be additional monies paid to the provider. However, some of the adjustments will be neutral and a few may result in a provider overpayment.
Monitor your authorization list and confirm the participation amount is correct for each resident. Contact your Case Manager if the amount of participation is different than you are expecting based on letters you’ve received from the department. For more information about who to contact if you need help reviewing your remittance advice or adjusting your claims refer to this Dear Provider Letter.
If you receive notice that this adjustment has resulted in an overpayment and you are a member of the AFH Council, we can help. Please contact us at info@adultfamilyhomecouncil.org.
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